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Mikesell L, O'Malley DM, Kurtzman RT, Howard J, Bates B, Hemler JR, Fadem SJ, Ferrante JM, Bator A, Hudson SV, Crabtree BF. Identifying priority areas to support primary care engagement in breast cancer survivorship care: A Delphi study. Cancer Med 2024; 13:e7219. [PMID: 38686635 PMCID: PMC11058672 DOI: 10.1002/cam4.7219] [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: 11/16/2023] [Revised: 01/30/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024] Open
Abstract
INTRODUCTION Existing approaches in cancer survivorship care delivery have proven to be insufficient to engage primary care. This study aimed to identify stakeholder-informed priorities to improve primary care engagement in breast cancer survivorship care. METHODS Experts in U.S. cancer survivorship care delivery were invited to participate in a 4-round online Delphi panel to identify and evaluate priorities for defining and fostering primary care's engagement in breast cancer survivorship. Panelists were asked to identify and then assess (ratings of 1-9) the importance and feasibility of priority items to support primary care engagement in survivorship. Panelists were asked to review the group results and reevaluate the importance and feasibility of each item, aiming to reach consensus. RESULTS Respondent panelists (n = 23, response rate 57.5%) identified 31 priority items to support survivorship care. Panelists consistently rated three items most important (scored 9) but with uncertain feasibility (scored 5-6). These items emphasized the need to foster connections and improve communication between primary care and oncology. Panelists reached consensus on four items evaluated as important and feasible: (1) educating patients on survivorship, (2) enabling screening reminders and monitoring alerts in the electronic medical record, (3) identifying patient resources for clinicians to recommend, and (4) distributing accessible reference guides of common breast cancer drugs. CONCLUSION Role clarity and communication between oncology and primary care were rated as most important; however, uncertainty about feasibility remains. These findings indicate that cross-disciplinary capacity building to address feasibility issues may be needed to make the most important priority items actionable in primary care.
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Affiliation(s)
- Lisa Mikesell
- School of Communication and InformationRutgers UniversityNew BrunswickNew JerseyUSA
- Institute for Health, Health Care Policy, and Aging ResearchRutgers UniversityNew BrunswickNew JerseyUSA
| | - Denalee M. O'Malley
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Rachel T. Kurtzman
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- NORC at The University of ChicagoChicagoIllinoisUSA
| | - Jenna Howard
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Benjamin Bates
- Institute for Health, Health Care Policy, and Aging ResearchRutgers UniversityNew BrunswickNew JerseyUSA
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
- Department of Medicine, Division of General Internal MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Jennifer R. Hemler
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Sarah J. Fadem
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Jeanne M. Ferrante
- Institute for Health, Health Care Policy, and Aging ResearchRutgers UniversityNew BrunswickNew JerseyUSA
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Alicja Bator
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
| | - Shawna V. Hudson
- Institute for Health, Health Care Policy, and Aging ResearchRutgers UniversityNew BrunswickNew JerseyUSA
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
| | - Benjamin F. Crabtree
- Department of Family MedicineRutgers Robert Wood Johnson Medical SchoolNew BrunswickNew JerseyUSA
- Rutgers Cancer Institute of New JerseyNew BrunswickNew JerseyUSA
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Jimenez ME, Uthirasamy N, Hemler JR, Bator A, Malke K, Lima D, Strickland PO, Ramachandran U, Crabtree BF, Hudson SV, Mackie TI, Mendelsohn AL. Maximizing the impact of reach out and read literacy promotion:anticipatory guidance and modeling. Pediatr Res 2024; 95:1644-1648. [PMID: 38062258 DOI: 10.1038/s41390-023-02945-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 05/26/2024]
Abstract
BACKGROUND Reach Out and Read (ROR) is a multi-component pediatric literacy promotion intervention. However, few studies link ROR components to outcomes. We examine associations between receipt of (1) multiple ROR components and (2) clinician modeling, a potential best practice, with enhanced home literacy environments (EHLEs) among Latino families. METHODS We conducted secondary analyses of cross-sectional enrollment data from a randomized clinical trial at three urban community health centers between November 2020 and June 2023. Latino parents with infants 6-<9 months old were surveyed about ROR component receipt (children's book, anticipatory guidance, modeling) and EHLE (StimQ2- Infant Read Scale). We used mixed models with clinician as a random effect, adjusting for covariates. RESULTS 440 Latino parent-infant dyads were included. With no components as the reference category, receipt of 1 component was not associated with EHLE. Receipt of 2 components (standardized beta = 0.27; 95%CI: 0.12-0.42) and 3 components (standardized beta = 0.33; 95% CI: 0.19-0.47) were associated with EHLE. In separate analyses, modeling was associated with EHLE (standardized beta = 0.16; 95%CI: 0.06-0.26). CONCLUSION Findings support modeling as a core ROR component. Programs seeking to enhance equity by promoting EHLE should utilize such strategies as anticipatory guidance and clinician modeling in addition to book distribution. IMPACT Reach Out and Read, a multi-component literacy promotion intervention, leverages primary care to promote equity in children's early language experiences. However, few studies link Reach Out and Read components to outcomes. Among Latino parent-infant dyads, we found that implementation of two and three components, compared to none, was associated with enhanced home literacy environments, following a dose response pattern. Parent report of clinician modeling was associated with enhanced home literacy environments. Literacy promotion programs seeking to enhance equity by promoting enhanced home literacy environments should utilize strategies in addition to book distribution, including anticipatory guidance and modeling, to maximize impact.
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Affiliation(s)
- Manuel E Jimenez
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Children's Specialized Hospital, New Brunswick, NJ, USA.
| | - Nila Uthirasamy
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jennifer R Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alicja Bator
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Keanaan Malke
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Daniel Lima
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Usha Ramachandran
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Thomas I Mackie
- Department of Health Policy and Management, School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, NY, USA
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Ventres WB, Stone LA, LaVallee LA, Loxterkamp D, Brown JR, Waxman DM, Dorward PS, Cawse-Lucas J, Mauksch LB, Kieber-Emmons AM, Crabtree BF, Miller WL, Brohm VM, Daaleman TP, Bossenbroek Fedoriw K. Storylines of family medicine VI: ways of being-in the office with patients. Fam Med Community Health 2024; 12:e002793. [PMID: 38609089 PMCID: PMC11029328 DOI: 10.1136/fmch-2024-002793] [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: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Lisa A LaVallee
- MAHEC Family Medicine Residency, Mountain Area Health Education Center, Asheville, North Carolina, USA
| | | | - Jonisha R Brown
- Family Medicine, Atrium Health, Charlotte, North Carolina, USA
| | - Dael M Waxman
- Family Medicine, Atrium Health, Charlotte, North Carolina, USA
| | | | - Jeanne Cawse-Lucas
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Larry B Mauksch
- Family Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | - Autumn M Kieber-Emmons
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Benjamin F Crabtree
- Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
- Cancer Institute of New Jersey, New Brunswick, New Jersey, USA
| | - William L Miller
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Veronica M Brohm
- Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
- Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Timothy P Daaleman
- Family Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA
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Fadem SJ, Crabtree BF, O'Malley DM, Mikesell L, Ferrante JM, Toppmeyer DL, Ohman-Strickland PA, Hemler JR, Howard J, Bator A, April-Sanders A, Kurtzman R, Hudson SV. Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study. BMC Prim Care 2023; 24:235. [PMID: 37946132 PMCID: PMC10634067 DOI: 10.1186/s12875-023-02186-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/17/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Advances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery. METHODS This protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation. DISCUSSION Study findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites. TRIAL REGISTRATION Registered with ClinicalTrials.gov on June 2, 2022: NCT05400941.
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Affiliation(s)
- Sarah J Fadem
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Denalee M O'Malley
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | - Lisa Mikesell
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
- School of Communication and Information, Rutgers University, New Brunswick, NJ, USA
| | - Jeanne M Ferrante
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA
| | | | | | - Jennifer R Hemler
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jenna Howard
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Alicja Bator
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Rachel Kurtzman
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- NORC at the University of Chicago, Bethesda, MD, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, NJ, USA.
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Garcia S, Shin M, Sloan K, Dang E, Garcia CO, Baezconde-Garbanati L, Palinkas LA, Crabtree BF, Tsui J. Disruptions to and Innovations in HPV Vaccination Strategies within Safety-Net Healthcare Settings Resulting from the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:2380. [PMID: 37685414 PMCID: PMC10486876 DOI: 10.3390/healthcare11172380] [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: 05/04/2023] [Revised: 08/22/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
The COVID-19 pandemic disrupted healthcare delivery within safety-net settings. Barriers to and facilitators of human papillomavirus (HPV) vaccination during the pandemic can inform future HPV vaccine strategies for underserved communities. Qualitative interviews (n = 52) between December 2020 and January 2022 in Los Angeles and New Jersey were conducted with providers, clinic leaders, clinic staff, advocates, payers, and policy-level representatives involved in the HPV vaccine process. Using the updated Consolidated Framework for Implementation Research we identified (1) outer setting barriers (i.e., vaccine hesitancy driven by social media, political views during the pandemic) and facilitators (e.g., partnerships); (2) inner setting clinic facilitators (i.e., motivation-driven clinic metrics, patient outreach, vaccine outreach events); (3) individual characteristics such as patient barriers (i.e., less likely to utilize clinic services during the pandemic and therefore, additional outreach to address missed vaccine doses are needed); (4) innovations in HPV vaccination strategies (i.e., clinic workflow changes to minimize exposure to COVID-19, leveraging new community partnerships (e.g., with local schools)); and (5) implementation strategies (i.e., multisectoral commitment to HPV goals). Pandemic setbacks forced safety-net settings to develop new vaccine approaches and partnerships that may translate to new implementation strategies for HPV vaccination within local contexts and communities.
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Affiliation(s)
- Samantha Garcia
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
| | - Michelle Shin
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA 98195, USA;
| | - Kylie Sloan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
| | - Emily Dang
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
| | - Carlos Orellana Garcia
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
| | - Lourdes Baezconde-Garbanati
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Lawrence A. Palinkas
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA 90089, USA;
| | - Benjamin F. Crabtree
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ 08901, USA;
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ 08901, USA
| | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA 90032, USA; (S.G.); (K.S.); (E.D.); (C.O.G.); (L.B.-G.)
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA 90033, USA
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Shin MB, Sloan K, Baezconde-Garbanati L, Dang E, Garcia S, Palinkas LA, Unger JB, Willgerodt M, Crabtree BF, Tsui J. Multilevel perspectives on school-based opportunities to improve HPV vaccination among medically underserved adolescents: Beyond school entry mandates. Hum Vaccin Immunother 2023; 19:2251815. [PMID: 37666253 PMCID: PMC10478734 DOI: 10.1080/21645515.2023.2251815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 09/06/2023] Open
Abstract
School-based HPV vaccination programs have improved vaccine uptake among adolescents globally. However, school-based HPV vaccination strategies in the United States (US) have mainly focused on school-entry mandates for vaccination, which have passed in only five states/jurisdictions. Many schools and school-based health centers (SBHCs) already provide health services to medically underserved adolescents and opportunities to improve disparities in HPV vaccine education and uptake are underexplored. This qualitative study of clinic and community members assessed potential opportunities within and outside schools to increase HPV vaccination. Data were generated from a larger mixed-methods study designed to understand experiences with HPV vaccination evidence-based strategies in medically underserved communities. The parent study included interviews and focus groups conducted with clinic (providers, clinic leaders, staff) and community (racial/ethnic minority parents, advocates, payers, policy representatives) members in Los Angeles and New Jersey between December 2020-January 2022. We created a reduced dataset of text related to schools/SBHCs (30 in-depth interviews, 7 focus groups) and conducted a directed content analysis. Participants indicated that schools and SBHCs are ideal venues for reaching medically underserved adolescents experiencing barriers to primary care access. Parents/providers expressed mutual interest in HPV vaccine administration/education in schools, but some advocates/policy participants experienced challenges due to increasing politicization of vaccines. Participants highlighted policies for expanding HPV vaccine education and administration in schools, including minor consent and increasing SBHC funding for HPV vaccines. More research is needed to explore existing infrastructure, partner motivation, and opportunities to improve HPV vaccination among medically underserved adolescents within schools beyond vaccine mandates.
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Affiliation(s)
- Michelle B. Shin
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WAUSA
| | - Kylie Sloan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lourdes Baezconde-Garbanati
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Emily Dang
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Samantha Garcia
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Lawrence A. Palinkas
- USC Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B. Unger
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Mayumi Willgerodt
- Department of Child, Family, and Population Health Nursing, School of Nursing, University of Washington, Seattle, WAUSA
| | | | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
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Tsui J, Shin M, Sloan K, Martinez B, Palinkas LA, Baezconde-Garbanati L, Cantor JC, Hudson SV, Crabtree BF. Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings. Prev Sci 2023:10.1007/s11121-023-01568-4. [PMID: 37368117 DOI: 10.1007/s11121-023-01568-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.
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Affiliation(s)
- Jennifer Tsui
- University of Southern California, Los Angeles, CA, USA.
| | | | - Kylie Sloan
- University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Joel C Cantor
- Rutgers the State University of New Jersey, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Rutgers the State University of New Jersey, New Brunswick, NJ, USA
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8
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Russell G, Lane R, Neil J, Advocat J, Sturgiss EA, Staunton Smith T, Alexander K, Hattle S, Crabtree BF, Miller WL. At the edge of chaos: a prospective multiple case study in Australian general practices adapting to COVID-19. BMJ Open 2023; 13:e064266. [PMID: 36657761 PMCID: PMC9852738 DOI: 10.1136/bmjopen-2022-064266] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES The rapid onset and progressive course of the COVID-19 pandemic challenged primary care practices to generate rapid solutions to unique circumstances, creating a natural experiment of effectiveness, resilience, financial stability and governance across primary care models. We aimed to characterise how practices in Melbourne, Australia modified clinical and organisational routines in response to the pandemic in 2020-2021 and identify factors that influenced these changes. DESIGN Prospective, qualitative, participatory case study design using constant comparative data analysis, conducted between April 2020 and February 2021. Participant general practitioner (GP) investigators were involved in study design, recruitment of other participants, data collection and analysis. Data analysis included investigator diaries, structured practice observation, documents and interviews. SETTING The cases were six Melbourne practices of varying size and organisational model. PARTICIPANTS GP investigators approached potential participants. Practice healthcare workers were interviewed by social scientists on three occasions, and provided feedback on presentations of preliminary findings. RESULTS We conducted 58 interviews with 26 practice healthcare workers including practice owners, practice managers, GPs, receptionists and nurses; and six interviews with GP investigators. Data saturation was achieved within each practice and across the sample. The pandemic generated changes to triage, clinical care, infection control and organisational routines, particularly around telehealth. While collaboration and trust increased within several practices, others fragmented, leaving staff isolated and demoralised. Financial and organisational stability, collaborative problem solving, creative leadership and communication (internally and within the broader healthcare sector) were major influences on practice ability to negotiate the pandemic. CONCLUSIONS This study demonstrates the complex influences on primary care practices, and reinforces the strengths of clinician participation in research design, conduct and analysis. Two implications are: telehealth, triage and infection management innovations are likely to continue; the existing payment system provides inadequate support to primary care in a global pandemic.
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Affiliation(s)
- Grant Russell
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Riki Lane
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Jennifer Neil
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Jenny Advocat
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Elizabeth Ann Sturgiss
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Timothy Staunton Smith
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Karyn Alexander
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Simon Hattle
- Department of General Practice, Monash University Faculty of Medicine, Nursing and Health Sciences, Notting Hill, Victoria, Australia
| | - Benjamin F Crabtree
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
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Pellerano MB, Hill D, Jimenez ME, Gordon M, Macenat M, Ferrante JM, Rivera-Núñez Z, Devance D, Lima D, Sullivan B, Crabtree BF, Georgopoulos P, Barrett ES, Reed DJ, Pernell CT, Dawkins MR, Lynn B, Dixon F, Castañeda M, Garcia H, Blaser MJ, Panettieri RA, Hudson SV. Connect: Cultivating Academic-Community Partnerships to Address Our Communities' Complex Needs During Public Health Crises. Prog Community Health Partnersh 2023; 17:447-464. [PMID: 37934443 PMCID: PMC11041973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
BACKGROUND Black and Latino communities have been disproportionately impacted by coronavirus disease 2019 and we sought to understand perceptions and attitudes in four heavily impacted New Jersey counties to develop and evaluate engagement strategies to enhance access to testing. OBJECTIVE To establish a successful academic/community partnership team during a public health emergency by building upon longstanding relationships and using principles from community engaged research. METHODS We present a case study illustrating multiple levels of engagement, showing how we successfully aligned expectations, developed a commitment of cooperation, and implemented a research study, with community-based and health care organizations at the center of community engagement and recruitment. LESSONS LEARNED This paper describes successful approaches to relationship building including information sharing and feedback to foster reciprocity, diverse dissemination strategies to enhance engagement, and intergenerational interaction to ensure sustainability. CONCLUSIONS This model demonstrates how academic/community partnerships can work together during public health emergencies to develop sustainable relationships.
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10
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Sloan K, Shin M, Palinkas LA, Hudson SV, Crabtree BF, Cantor JC, Tsui J. Exploring HPV vaccination policy and payer strategies for opportunities to improve uptake in safety-net settings. Front Public Health 2023; 11:1099552. [PMID: 37213634 PMCID: PMC10192548 DOI: 10.3389/fpubh.2023.1099552] [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: 11/15/2022] [Accepted: 04/11/2023] [Indexed: 05/23/2023] Open
Abstract
Introduction We explored priorities and perspectives on health policy and payer strategies for improving HPV vaccination rates in safety-net settings in the United States. Methods We conducted qualitative interviews with policy and payer representatives in the greater Los Angeles region and state of New Jersey between December 2020 and January 2022. Practice Change Model domains guided data collection, thematic analysis, and interpretation. Results Five themes emerged from interviews with 11 policy and 8 payer participants, including: (1) payer representatives not prioritizing HPV vaccination specifically in incentive-driven clinic metrics; (2) policy representatives noting region-specific HPV vaccine policy options; (3) inconsistent motivation across policy/payer groups to improve HPV vaccination; (4) targeting of HPV vaccination in quality improvement initiatives suggested across policy/payer groups; and (5) COVID-19 pandemic viewed as both barrier and opportunity for HPV vaccination improvement across policy/payer groups. Discussion Our findings indicate opportunities for incorporating policy and payer perspectives into HPV vaccine improvement processes. We identified a need to translate effective policy and payer strategies, such as pay-for-performance programs, to improve HPV vaccination within safety-net settings. COVID-19 vaccination strategies and community efforts create potential policy windows for expanding HPV vaccine awareness and access.
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Affiliation(s)
- Kylie Sloan
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Michelle Shin
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Lawrence A. Palinkas
- Department of Children, Youth, and Families, Suzanne Dworak-Peck School of Social Work University of Southern California, Los Angeles, CA, United States
| | - Shawna V. Hudson
- Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Benjamin F. Crabtree
- Department of Family Medicine and Community Health, Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Joel C. Cantor
- Center for State Health Policy, Rutgers, The State University of New Jersey, New Brunswick, NJ, United States
| | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Jennifer Tsui
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11
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Kurtzman RT, Barry K, Howard J, Hudson SV, Crabtree BF. Oncologists' Perspectives on Cancer Survivorship: What Role Should Primary Care Play? Cancer Control 2023; 30:10732748231195436. [PMID: 37622197 PMCID: PMC10467282 DOI: 10.1177/10732748231195436] [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: 08/26/2023] Open
Abstract
Background: Despite calls for an enhanced role for primary care for individuals with a history of cancer, primary medical care's role in adult survivorship care continues to be marginal.Methods: We conducted in-depth interviews with 8 medical oncologists with interest in cancer survivorship from 7 National Cancer Institute designated comprehensive cancer centers to understand perspectives on the role of primary care in cancer survivorship.Results: Two salient overarching thematic patterns emerged. (1) Oncologist's perspectives diverge on if, how, and when primary care clinicians should be involved in survivorship, ranging from involvement of primary care throughout treatment to a standardized hand-off years post-therapy. (2) Oncologist's lack understanding about primary care's expertise and subsequent value in survivorship care.Conclusion: As oncology continues to be overwhelmed by rising numbers of aging cancer survivors with multi-morbidities, NCI-designated cancer centers should take a leadership role in integrating primary care engaged cancer survivorship.
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Affiliation(s)
- Rachel T. Kurtzman
- Research Division, Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kacie Barry
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Jenna Howard
- Research Division, Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shawna V. Hudson
- Research Division, Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Benjamin F. Crabtree
- Research Division, Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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12
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O'Malley DM, Doose M, Howard J, Cantor JC, Crabtree BF, Tsui J. Understanding the Impact of Medicaid-Serving Primary Care Team Functioning and Clinical Context on Cancer Care Treatment Quality: Implications for Addressing Structural Inequities. JCO Oncol Pract 2023; 19:e92-e102. [PMID: 36473147 PMCID: PMC9870234 DOI: 10.1200/op.22.00295] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Primary care factors related to Medicaid enrollees' receipt of guideline concordant cancer treatment is understudied; however, team structure and processes likely affect care disparities. We explore Medicaid-serving primary care teams functioning within multiteam systems to understand performance variations in quality of breast and colorectal cancer care. METHODS We conducted a comparative case study, using critical case sampling of primary care clinics in New Jersey, to provide maximum variation on clinic-level care performance rates (Medicaid enrollees' receipt of guideline-concordant treatment). Site evaluations, conducted from 2019 to 2020, included observation (2-3 days) and interviews. Using a multistep analytic process, we explored contextual factors within primary care that may contribute to cancer care performance variations. RESULTS We identified performance variations stemming from adaptations of multiteam system inputs and processes on the basis of contextual factors (ie, business model, clinic culture). Team 1 (average performer), part of a multisite safety-net clinic system, mainly teamed outside their organization, relying on designated roles, protocol-based care, and quality improvement informed by within-team metrics. Team 2 (high performer), part of a for-profit health system, remained mission-driven to improve urban health, teamed exclusively with internal teams through electronically enabled information exchange and health system-wide quality improvement efforts. Team 3 (low performer), a physician-owned private practice with minimal teaming, accepted Medicaid enrollees to diversify their payer mix and relied on referral-based care with limited consideration of social barriers. CONCLUSION Primary care team structures and processes variations may (in part) explain performance variations. Future research aiming to improve care quality for Medicaid populations should consider primary care teams' capacity and context in relation to composite teams to support care quality improvements in subsequent prospective trials.
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Affiliation(s)
- Denalee M. O'Malley
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Research Division, New Brunswick NJ
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Michelle Doose
- Division of Clinical and Health Services Research, National Institute on Minority Health and Health Disparities, Bethesda, MD
| | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Research Division, New Brunswick NJ
| | - Joel C. Cantor
- Rutgers Center for State Health Policy, New Brunswick, NJ
| | - Benjamin F. Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, Research Division, New Brunswick NJ
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Jennifer Tsui
- Department of Population and Public Health Sciences, Keck School of Medicine at USC, University of Southern California, Los Angeles, CA
- Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA
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Jimenez ME, Hemler JR, Uthirasamy N, Bator A, Forbes DH, Lucas M, Ramachandran U, Crabtree BF, Mackie TI. A Mixed-Methods Investigation Examining Site-Level Variation in Reach Out and Read Implementation. Acad Pediatr 2022:S1876-2859(22)00574-5. [PMID: 36496152 DOI: 10.1016/j.acap.2022.11.015] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/22/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Reach Out and Read (ROR) is an evidence-based early childhood intervention that has been implemented at scale, yet description of ROR implementation is inconsistent. This study engages implementation science to examine ROR delivery and site-level variation. METHODS As part of an ongoing clinical trial, we conducted a mixed-methods study in 3 community health centers (CHCs) that serve low-income Latino families. We integrated quantitative parent survey data, qualitative data from monthly key informant interviews with ROR site leaders over 1 year, and in-depth interviews with 18 additional clinicians. At enrollment, parents reported whether they received a children's book, guidance on reading, and modeling from clinicians. We analyzed quantitative data using descriptive statistics, and qualitative data iteratively engaging emergent and a priori codes drawn from the Template for Intervention Description and Replication Checklist. RESULTS Three hundred Latino parents (mean age: 31; 75% ≤HS education) completed surveys. The mean child age was 8 months. Overall, most parents reported receiving a book (84%) and guidance (73%), but fewer experienced modeling (23%). Components parents received varied across CHCs. Two themes emerged to explain the variation observed: 1) differences in the perceived purpose of shared reading and book delivery aligned with variation in implementation, and 2) site-level barriers affected what components were implemented. CONCLUSION Because of substantive variation in ROR implementation across sites, systematic descriptions using established frameworks and corresponding measurement to characterize ROR implementation may enhance our understanding of mechanisms underlying ROR's effects, which clinicians and policymakers can use to maximize ROR's impact.
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Affiliation(s)
- Manuel E Jimenez
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (ME Jimenez and U Ramachandran), New Brunswick, NJ; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, JR Hemler, N Uthirasamy, A Bator, and BF Crabtree), New Brunswick, NJ; Children's Specialized Hospital (ME Jimenez), New Brunswick, NJ.
| | - Jennifer R Hemler
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, JR Hemler, N Uthirasamy, A Bator, and BF Crabtree), New Brunswick, NJ
| | - Nila Uthirasamy
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, JR Hemler, N Uthirasamy, A Bator, and BF Crabtree), New Brunswick, NJ
| | - Alicja Bator
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, JR Hemler, N Uthirasamy, A Bator, and BF Crabtree), New Brunswick, NJ
| | - Darlene H Forbes
- Department of Pediatrics, Jewish Renaissance Medical Center (DH Forbes), Perth Amboy, NJ
| | - Michael Lucas
- Saint Peters University Hospital Pediatric Faculty Group (M Lucas), New Brunswick, NJ
| | - Usha Ramachandran
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (ME Jimenez and U Ramachandran), New Brunswick, NJ; Department of Pediatrics, Eric B. Chandler Health Center (U Ramachandran), New Brunswick, NJ
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, JR Hemler, N Uthirasamy, A Bator, and BF Crabtree), New Brunswick, NJ
| | - Thomas I Mackie
- Department of Health Policy and Management, SUNY Downstate Health Sciences University (TI Mackie), Brooklyn, NY
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Cohen DJ, Balasubramanian BA, Lindner S, Miller WL, Sweeney SM, Hall JD, Ward R, Marino M, Springer R, McConnell KJ, Hemler JR, Ono SS, Ezekiel-Herrera D, Baron A, Crabtree BF, Solberg LI. How Does Prior Experience Pay Off in Large-Scale Quality Improvement Initiatives? J Am Board Fam Med 2022:jabfm.2022.AP.220088. [PMID: 36113993 DOI: 10.3122/jabfm.2022.ap.220088] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 03/21/2023] Open
Abstract
INTRODUCTION To examine the association of prior investment on the effectiveness of organizations delivering large-scale external support to improve primary care. METHODS Mixed-methods study of 7 EvidenceNOW grantees (henceforth, Cooperatives) and their recruited practices (n = 1720). Independent Variable: Cooperatives's experience level prior to EvidenceNOW, defined as a sustained track record in delivering large-scale quality improvement (QI) to primary care practices (high, medium, or low). Dependent Variables: Implementation of external support, measured as facilitation dose; effectiveness at improving (1) clinical quality, measured as practices' performance on Aspirin, Blood Pressure, Cholesterol, and Smoking (ABCS); and (2) practice capacity, measured using the Adaptive Reserve (AR) score and Change Process Capacity Questionnaire (CPCQ). Data were analyzed using multivariable linear regressions and a qualitative inductive approach. RESULTS Cooperatives with High (vs low) levels of prior experience with and investment in large-scale QI before EvidenceNOW recruited more geographically dispersed and diverse practices, with lower baseline ABCS performance (differences ranging from 2.8% for blood pressure to 41.5% for smoking), delivered more facilitation (mean=+20.3 hours, P = .04), and made greater improvements in practices' QI capacity (CPCQ: +2.04, P < .001) and smoking performance (+6.43%, P = .003). These Cooperatives had established networks of facilitators at the start of EvidenceNOW and leadership experienced in supporting this workforce, which explained their better recruitment, delivery of facilitation, and improvement in outcomes. DISCUSSION Long-term investment that establishes regionwide organizations with infrastructure and experience to support primary care practices in QI is associated with more consistent delivery of facilitation support, and greater improvement in practice capacity and some clinical outcomes.
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Affiliation(s)
- Deborah J Cohen
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS).
| | - Bijal A Balasubramanian
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Stephan Lindner
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - William L Miller
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Shannon M Sweeney
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Jennifer D Hall
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Rikki Ward
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Miguel Marino
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Rachel Springer
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - K John McConnell
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Jennifer R Hemler
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Sarah S Ono
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - David Ezekiel-Herrera
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Andrea Baron
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Benjamin F Crabtree
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
| | - Leif I Solberg
- From Department of Family Medicine and Department of Medical and Clinical Epidemiology, Oregon Health & Science University, Portland, OR (DJC); Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, TX (BAB, RW); Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR (SL, KJM); Department of Family Medicine, Lehigh Valley Health Network, Allentown, PA (WLM); Department of Family Medicine, Oregon Health & Science University Portland, OR (SMS, JDH, MM, RS, DE-H, AB); Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (JRH, BFC); Department of Psychiatry and Department of Family Medicine, Oregon Health & Science University Portland, OR; VHA Office of Rural Health, Department of Veterans Affairs and VA Portland Health Care System, Portland, OR (SSO); HealthPartners Institute, Minneapolis MN (LIS)
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Margolis KL, Crain AL, Green BB, O'Connor PJ, Solberg LI, Beran M, Bergdall AR, Pawloski PA, Ziegenfuss JY, JaKa MM, Appana D, Sharma R, Kodet AJ, Trower NK, Rehrauer DJ, McKinney Z, Norton CK, Haugen P, Anderson JP, Crabtree BF, Norman SK, Sperl-Hillen JM. Comparison of explanatory and pragmatic design choices in a cluster-randomized hypertension trial: effects on enrollment, participant characteristics, and adherence. Trials 2022; 23:673. [PMID: 35978336 PMCID: PMC9387034 DOI: 10.1186/s13063-022-06611-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Explanatory trials are designed to assess intervention efficacy under ideal conditions, while pragmatic trials are designed to assess whether research-proven interventions are effective in “real-world” settings without substantial research support. Methods We compared two trials (Hyperlink 1 and 3) that tested a pharmacist-led telehealth intervention in adults with uncontrolled hypertension. We applied PRagmatic Explanatory Continuum Indicator Summary-2 (PRECIS-2) scores to describe differences in the way these studies were designed and enrolled study-eligible participants, and the effect of these differences on participant characteristics and adherence to study interventions. Results PRECIS-2 scores demonstrated that Hyperlink 1 was more explanatory and Hyperlink 3 more pragmatic. Recruitment for Hyperlink 1 was conducted by study staff, and 2.9% of potentially eligible patients enrolled. Enrollees were older, and more likely to be male and White than non-enrollees. Study staff scheduled the initial pharmacist visit and adherence to attending this visit was 98%. Conversely for Hyperlink 3, recruitment was conducted by clinic staff at routine encounters and 81% of eligible patients enrolled. Enrollees were younger, and less likely to be male and White than non-enrollees. Study staff did not assist with scheduling the initial pharmacist visit and adherence to attending this visit was only 27%. Compared to Hyperlink 1, patients in Hyperlink 3 were more likely to be female, and Asian or Black, had lower socioeconomic indicators, and were more likely to have comorbidities. Owing to a lower BP for eligibility in Hyperlink 1 (>140/90 mm Hg) than in Hyperlink 3 (>150/95 mm Hg), mean baseline BP was 148/85 mm Hg in Hyperlink 1 and 158/92 mm Hg in Hyperlink 3. Conclusion The pragmatic design features of Hyperlink 3 substantially increased enrollment of study-eligible patients and of those traditionally under-represented in clinical trials (women, minorities, and patients with less education and lower income), and demonstrated that identification and enrollment of a high proportion of study-eligible subjects could be done by usual primary care clinic staff. However, the trade-off was much lower adherence to the telehealth intervention than in Hyperlink 1, which is likely to reflect uptake under real-word conditions and substantially dilute intervention effect on BP. Trial registration The Hyperlink 1 study (NCT00781365) and the Hyperlink 3 study (NCT02996565) are registered at ClinicalTrials.gov.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA, 98101, USA
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - MarySue Beran
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Meghan M JaKa
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Deepika Appana
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Amy J Kodet
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Daniel J Rehrauer
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Christine K Norton
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ, 08901, USA
| | - Sarah K Norman
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 21112R, PO Box 1524, Minneapolis, MN, 55440-1524, USA
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Kieber-Emmons AM, Miller WL, Rubinstein EB, Howard J, Tsui J, Rankin JL, Crabtree BF. A Novel Mixed Methods Approach Combining Geospatial Mapping and Qualitative Inquiry to Identify Multilevel Policy Targets: The Focused Rapid Assessment Process (fRAP) Applied to Cancer Survivorship. J Mix Methods Res 2022; 16:183-206. [PMID: 35603123 PMCID: PMC9122103 DOI: 10.1177/1558689820984273] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Multi-level perspectives across communities, medical systems and policy environments are needed, but few methods are available for health services researchers with limited resources. We developed a mixed method health policy approach, the focused Rapid Assessment Process (fRAP), that is designed to uncover multi-level modifiable barriers and facilitators contributing to public health issues. We illustrate with a study applying fRAP to the issue of cancer survivorship care. Through this multi-level investigation we identified two major modifiable areas impacting high-quality cancer survivorship care: 1) the importance of cancer survivorship guidelines/data, 2) the need for improved oncology-primary care relationships. This article contributes to the mixed methods literature by coupling geospatial mapping to qualitative rapid assessment to efficiently identify policy change targets.
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Affiliation(s)
- Autumn M Kieber-Emmons
- Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, One City Center, 707 Hamilton St, Allentown, PA, 18101, USA
| | - William L Miller
- Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, One City Center, 707 Hamilton St, Allentown, PA, 18101, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Minard Hall 428, Fargo, ND, 58102 USA
| | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, 112 Patterson St, New Brunswick, NJ 08901, USA
| | - Jennifer Tsui
- Department of Preventative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033 USA
| | - Jennifer L Rankin
- HealthLandscape, American Academy of Family Physicians, Washington, D.C., USA
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, 112 Patterson St, New Brunswick, NJ 08901, USA
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17
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O'Malley DM, Abraham CM, Lee HS, Rubinstein EB, Howard J, Hudson SV, Kieber-Emmons AM, Crabtree BF. Substance use disorder approaches in US primary care clinics with national reputations as workforce innovators. Fam Pract 2022; 39:282-291. [PMID: 34423366 PMCID: PMC8956130 DOI: 10.1093/fampra/cmab095] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Over the last decade, primary care clinics in the United States have responded both to national policies encouraging clinics to support substance use disorders (SUD) service expansion and to regulations aiming to curb the opioid epidemic. OBJECTIVE To characterize approaches to SUD service expansion in primary care clinics with national reputations as workforce innovators. METHODS Comparative case studies were conducted to characterize different approaches among 12 primary care clinics purposively and iteratively recruited from a national registry of workforce innovators. Observational field notes and qualitative interviews from site visits were coded and analysed to identify and characterize clinic attributes. RESULTS Codes describing clinic SUD expansion approaches emerged from our analysis. Clinics were characterized as: avoidant (n = 3), contemplative (n = 5) and responsive (n = 4). Avoidant clinics were resistant to planning SUD service expansion; had no or few on-site behavioural health staff; and lacked on-site medication treatment (previously termed medication-assisted therapy) waivered providers. Contemplative clinics were planning or had partially implemented SUD services; members expressed uncertainties about expansion; had co-located behavioural healthcare providers, but no on-site medication treatment waivered and prescribing providers. Responsive clinics had fully implemented SUD; members used non-judgmental language about SUD services; had both co-located SUD behavioural health staff trained in SUD service provision and waivered medication treatment physicians and/or a coordinated referral pathway. CONCLUSIONS Efforts to support SUD service expansion should tailor implementation supports based on specific clinic training and capacity building needs. Future work should inform the adaption of evidence-based practices that are responsive to resource constraints to optimize SUD treatment access.
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Affiliation(s)
- Denalee M O'Malley
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Cilgy M Abraham
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Heather S Lee
- Department of Anthropology, Sociology, Social Work and Criminal Justice, Seton Hall University, South Orange, NJ, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, Fargo, ND, USA
| | - Jenna Howard
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Autumn M Kieber-Emmons
- Lehigh Valley Health Network/University of Southern Florida Morsani School of Medicine, Allentown, PA, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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18
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Rivera-Núñez Z, Jimenez ME, Crabtree BF, Hill D, Pellerano MB, Devance D, Macenat M, Lima D, Gordon M, Sullivan B, Rosati RJ, Ferrante JM, Barrett ES, Blaser MJ, Panettieri RA, Hudson SV. Experiences of Black and Latinx health care workers in support roles during the COVID-19 pandemic: A qualitative study. PLoS One 2022; 17:e0262606. [PMID: 35041702 PMCID: PMC8765643 DOI: 10.1371/journal.pone.0262606] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 12/29/2021] [Indexed: 11/18/2022] Open
Abstract
Black and Latinx individuals, and in particular women, comprise an essential health care workforce often serving in support roles such as nursing assistants and dietary service staff. Compared to physicians and nurses, they are underpaid and potentially undervalued, yet play a critical role in health systems. This study examined the impact of the coronavirus disease 2019 (COVID-19) pandemic from the perspective of Black and Latinx health care workers in support roles (referred to here as HCWs). From December 2020 to February 2021, we conducted 2 group interviews (n = 9, 1 group in English and 1 group in Spanish language) and 8 individual interviews (1 in Spanish and 7 in English) with HCWs. Participants were members of a high-risk workforce as well as of communities that suffered disproportionately during the pandemic. Overall, they described disruptive changes in responsibilities and roles at work. These disruptions were intensified by the constant fear of contracting COVID-19 themselves and infecting their family members. HCWs with direct patient care responsibilities reported reduced opportunities for personal connection with patients. Perspectives on vaccines reportedly changed over time, and were influenced by peers' vaccination and information from trusted sources. The pandemic has exposed the stress endured by an essential workforce that plays a critical role in healthcare. As such, healthcare systems need to dedicate resources to improve the work conditions for this marginalized workforce including offering resources that support resilience. Overall working conditions and, wages must be largely improved to ensure their wellbeing and retain them in their roles to manage the next public health emergency. The role of HCWs serving as ambassadors to provide accurate information on COVID-19 and vaccination among their coworkers and communities also warrants further study.
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Affiliation(s)
- Zorimar Rivera-Núñez
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey, United States of America
| | - Manuel E. Jimenez
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Benjamin F. Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Diane Hill
- University-Community Partnerships, Rutgers School of Public Affairs and Administration, Rutgers University, Newark, New Jersey, United States of America
| | - Maria B. Pellerano
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Donita Devance
- University-Community Partnerships, Rutgers University, Newark, New Jersey, United States of America
| | - Myneka Macenat
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Daniel Lima
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Marsha Gordon
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Brittany Sullivan
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Robert J. Rosati
- Connected Health Institute, VNA Health Group, Holmdel, New Jersey, United States of America
| | - Jeanne M. Ferrante
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Emily S. Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey, United States of America
| | - Martin J. Blaser
- Departments of Medicine and Pathology, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Advance Biotechnology and Medicine, New Brunswick, New Jersey, United States of America
| | - Reynold A. Panettieri
- Rutgers Institute for Translational Medicine and Science, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
| | - Shawna V. Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States of America
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19
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Desai J, Saman D, Sperl-Hillen JM, Pratt R, Dehmer SP, Allen C, Ohnsorg K, Wuorio A, Appana D, Hitz P, Land A, Sharma R, Wilkerson L, Crain AL, Crabtree BF, Bianco J, O'Connor PJ. Implementing a prediabetes clinical decision support system in a large primary care system: Design, methods, and pre-implementation results. Contemp Clin Trials 2022; 114:106686. [DOI: 10.1016/j.cct.2022.106686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
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20
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Solberg LI, Hooker SA, Rossom RC, Bergdall A, Crabtree BF. Clinician Perceptions About a Decision Support System to Identify and Manage Opioid Use Disorder. J Am Board Fam Med 2021; 34:1096-1102. [PMID: 34772765 PMCID: PMC8759280 DOI: 10.3122/jabfm.2021.06.210126] [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: 03/25/2021] [Revised: 06/02/2021] [Accepted: 06/04/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Addressing the opioid epidemic would benefit from primary care clinicians identifying and managing opioid use disorder (OUD) during routine clinical encounters, but current rates are low. Clinical decision support (CDS) systems are a promising way to facilitate such interactions, but will clinicians use them? METHODS We iteratively conducted semi-structured interviews with 8 purposively sampled primary care clinicians participating in a pilot OUD-CDS study to identify attitudes toward discussing OUD and preferences for support in doing so. Five of them had used a pilot version of the CDS for 6 months, while the others were in comparison clinics. Interviews were recorded, transcribed, and analyzed by a multi-disciplinary group of experienced researchers, using an editing organizing style where the analysts independently highlighted relevant text and then discussed to reach a consensus on themes. RESULTS We identified five themes: 1. Primary care is the right place to address OUD. 2. Both clinician-patient and clinician-clinician relationships affect how and whether clinicians address OUD in a particular patient encounter. 3. The main challenges are limited time and competing priorities for these complex patients. 4. Although a CDS for OUD could be very helpful, it must meet different needs for different clinicians and clinical situations and be simple to use. 5. For optimal benefit, the CDS needs to be complemented by supportive organizational policies and systems as well as local clinician encouragement. CONCLUSIONS With the right design and a supportive organization, these primary care clinicians believe a CDS could help them regularly identify and address OUD among their patients as long as it incorporates their concerns about relationships, competing priorities, patient complexity, and user simplicity.
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Affiliation(s)
- Leif I Solberg
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC).
| | - Stephanie A Hooker
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Rebecca C Rossom
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Anna Bergdall
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
| | - Benjamin F Crabtree
- From the HealthPartners Institute, Minneapolis, MN (LIS, SAH, RCR, AB); Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ (BFC)
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21
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Russell G, Advocat J, Lane R, Neil J, Staunton-Smith T, Alexander KE, Hattle S, Crabtree BF, Miller WL, Setunge SN, Sturgiss EA. How do general practices respond to a pandemic? Protocol for a prospective qualitative study of six Australian practices. BMJ Open 2021; 11:e046086. [PMID: 34521660 PMCID: PMC8441220 DOI: 10.1136/bmjopen-2020-046086] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic has transformed healthcare systems worldwide. Primary care providers have been at the forefront of the pandemic response and have needed to rapidly adjust processes and routines around service delivery. The pandemic provides a unique opportunity to understand how general practices prepare for and respond to public health emergencies. We will follow a range of general practices to characterise the changes to, and factors influencing, modifications to clinical and organisational routines within Australian general practices amidst the COVID-19 pandemic. METHODS AND ANALYSIS This is a prospective case study of multiple general practices using a participatory approach for design, data collection and analysis. The study is informed by the sociological concept of routines and will be set in six general practices in Melbourne, Australia during the 2020-2021 COVID-19 pandemic. General practitioners associated with the Monash University Department of General Practice will act as investigators who will shape the project and contribute to the data collection and analysis. The data will include investigator diaries, an observation template and interviews with practice staff and investigators. Data will first be analysed by two external researchers using a constant comparative approach and then later refined at regular investigator meetings. Cross-case analysis will explain the implementation, uptake and sustainability of routine changes that followed the commencement of the pandemic. ETHICS AND DISSEMINATION Ethics approval was granted by Monash University (23950) Human Research Ethics Committees. Practice reports will be made available to all participating practices both during the data analysis process and at the end of the study. Further dissemination will occur via publications and presentations to practice staff and medical practitioners.
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Affiliation(s)
- Grant Russell
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jenny Advocat
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Riki Lane
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Jennifer Neil
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Timothy Staunton-Smith
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Karyn E Alexander
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- Altona North Medical Group, Altona North, Victoria, Australia
| | - Simon Hattle
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - William L Miller
- Department of Family Medicine, Leigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Sumudu Neilya Setunge
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
| | - Elizabeth Ann Sturgiss
- Department of General Practice, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
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22
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Jimenez ME, Crabtree BF, Hudson SV, Mendelsohn AL, Lima D, Shelton PA, Veras J, Lin Y, Pellerano M, Morrow L, Strom BL. Enhancing Reach Out and Read With a Video and Text Messages: A Randomized Trial in a Low-Income Predominantly Latino Sample. Acad Pediatr 2021; 21:968-976. [PMID: 33618060 PMCID: PMC8349760 DOI: 10.1016/j.acap.2021.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 02/12/2021] [Accepted: 02/16/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the effect of adding a video and text messages to Reach Out and Read (ROR) on parent-reported literacy activities compared to the standard version. STUDY DESIGN We conducted a mixed methods hybrid type I effectiveness-implementation randomized trial in a community health center that serves low-income Latino families. We assessed shared reading frequency and the StimQ Reading subscale, at enrollment and 6-month follow-up and the StimQ Parent Verbal Responsivity subscale, Parent Reading Belief Inventory, and Survey of Wellbeing of Young Children-Milestones at follow-up. We randomized 160 parent-child dyads to ROR or ROR plus video and text messages (enhanced ROR). We collected process data on ROR and engagement with texts. We interviewed 15 enhanced ROR participants. We analyzed quantitative data using regression and qualitative data using immersion/crystallization. RESULTS One hundred thirty-seven parent-child dyads completed the study (87% Latino, mean child age 9 months). We found differences in the StimQ Reading subscale (B = 0.32; P = .034) and marginal differences in attitudes about reading favoring enhanced ROR. Between-group differences for shared reading frequency, verbal responsivity, and developmental delay were not significant. Qualitative themes provided insight into the enhanced ROR including how it encouraged parents, remaining barriers like competing priorities and lack of social support, and unanticipated benefits (ie, parent appreciation for attention on their families' wellbeing). CONCLUSIONS A video and text message enhancement to ROR resulted in modest improvements in the home literacy environment over ROR alone. Additional strategies are needed to overcome potent barriers faced by low-income families.
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Affiliation(s)
- Manuel E Jimenez
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (ME Jimenez, D Lima, and PA Shelton), New Brunswick, NJ; Boggs Center on Developmental Disabilities, Rutgers Robert Wood Johnson Medical School (ME Jimenez), New Brunswick, NJ; Child Health Institute of New Jersey, Rutgers Robert Wood Johnson Medical School (ME Jimenez), New Brunswick, NJ; Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, BF Crabtree, SV Hudson, and M Pellerano), New Brunswick, NJ; Children's Specialized Hospital (ME Jimenez), New Brunswick, NJ.
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, BF Crabtree, SV Hudson, and M Pellerano), New Brunswick, NJ
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, BF Crabtree, SV Hudson, and M Pellerano), New Brunswick, NJ
| | | | - Daniel Lima
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (ME Jimenez, D Lima, and PA Shelton), New Brunswick, NJ
| | - Patricia A Shelton
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (ME Jimenez, D Lima, and PA Shelton), New Brunswick, NJ
| | - Julissa Veras
- School of Medicine and Dentistry University of Rochester (J Veras), Rochester, NY
| | - Yong Lin
- Rutgers School of Public Health (Y Lin), Piscataway, NJ
| | - Maria Pellerano
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School (ME Jimenez, BF Crabtree, SV Hudson, and M Pellerano), New Brunswick, NJ
| | - Lesley Morrow
- Rutgers Graduate School of Education (L Morrow), New Brunswick, NJ
| | - Brian L Strom
- Rutgers Biomedical Health Sciences (BL Strom), Newark, NJ
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23
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Tsui J, Vincent A, Anuforo B, Btoush R, Crabtree BF. Understanding primary care physician perspectives on recommending HPV vaccination and addressing vaccine hesitancy. Hum Vaccin Immunother 2021; 17:1961-1967. [PMID: 33439768 PMCID: PMC8189098 DOI: 10.1080/21645515.2020.1854603] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
HPV vaccination rates have improved in recent years, but remain suboptimal in the United States. Physician recommendation is associated with increased uptake; however, specific strategies used by physicians to recommend the vaccine and address hesitancy are underexplored. We iteratively conducted qualitative in-depth interviews with family medicine and pediatrics/adolescent medicine physicians recruited from four primary care settings (federally qualified health centers and hospital-affiliated practices) within a large academic-hospital system in New Jersey. Interviews aimed to understand factors influencing physician recommendations. Transcripts were analyzed iteratively using a team-based, thematic content analysis approach. All physicians reported strong support for HPV vaccination, intention to recommend for target age groups, and providing factsheets to parents. Many physicians used electronic medical records and/or the state immunization registry for monitoring vaccinations, but few were able to report their own clinic-level rates. The majority said they needed to overcome both hesitancy for at least 10-30% of parents and misinformation from the internet. Most cited having their own children vaccinated for HPV as a first-line strategy for addressing parental hesitancy. Other strategies included using data or professional authority to address safety concerns, linking HPV to cervical cancer, highlighting only needing two doses if vaccinated younger, and normalizing the vaccine. While our findings indicate physicians are knowledgeable about HPV vaccination and recommend it to parents, strategies to overcome parental hesitancy varied. Physician, clinic, and health-system-based strategies need to be adopted to overcome parental hesitancy for HPV vaccination.
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Affiliation(s)
- Jennifer Tsui
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ashley Vincent
- Medical Student, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Bianca Anuforo
- Division of Nursing Science, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Rula Btoush
- Division of Nursing Science, Rutgers School of Nursing, Newark, NJ, USA
| | - Benjamin F Crabtree
- Division of Nursing Science, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson, Medical School, New Brunswick, NJ, USA
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Jimenez ME, Rivera-Núñez Z, Crabtree BF, Hill D, Pellerano MB, Devance D, Macenat M, Lima D, Martinez Alcaraz E, Ferrante JM, Barrett ES, Blaser MJ, Panettieri RA, Hudson SV. Black and Latinx Community Perspectives on COVID-19 Mitigation Behaviors, Testing, and Vaccines. JAMA Netw Open 2021; 4:e2117074. [PMID: 34264327 PMCID: PMC8283554 DOI: 10.1001/jamanetworkopen.2021.17074] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Black and Latinx communities have been disproportionately affected by the COVID-19 pandemic, yet little work has sought to understand their perspectives. OBJECTIVE To explore the experiences of Black and Latinx communities during the pandemic to better understand their perspectives on COVID-19 mitigation behaviors (eg, mask wearing), testing, and vaccines. DESIGN, SETTING, AND PARTICIPANTS In this community-engaged qualitative study conducted with 18 community-based organizations and 4 health care organizations between November 19, 2020, and February 5, 2021, in New Jersey counties severely affected by the pandemic, group and individual interviews were used to purposively sample 111 Black and Latinx individuals. A total of 13 group interviews were organized by race/ethnicity and language: 4 English-speaking groups with Black participants (n = 34), 3 Spanish-speaking groups with Latinx participants (n = 24), and 4 English-speaking groups with Black and Latinx participants (n = 36). To understand the views of health care workers from these communities, 2 additional groups (n = 9) were convened and supplemented with individual interviews. MAIN OUTCOMES AND MEASURES Description of Black and Latinx participants' experiences during the COVID-19 pandemic and their perspectives on mitigation behaviors, testing, and vaccines. RESULTS The study included 111 participants (87 women [78.4%]; median age, 43 years [range, 18-93 years]). Participants described the devastating effects of the pandemic on themselves, loved ones, and their community. Their experiences were marked by fear, illness, loss, and separation. These experiences motivated intense information seeking, mitigation behaviors, and testing. Nevertheless, vaccine skepticism was high across all groups. Participants did not trust the vaccine development process and wanted clearer information. Black participants expressed that they did not want to be subjects of experiments. CONCLUSIONS AND RELEVANCE The remaining unknowns about new vaccines need to be acknowledged and described for Black and Latinx communities to make informed decisions. Ultimately, scientists and public officials need to work transparently to address unanswered questions and work collaboratively with trusted community leaders and health professionals to foster partnered approaches, rather than focusing on marketing campaigns, to eliminate vaccine skepticism.
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Affiliation(s)
- Manuel E. Jimenez
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Zorimar Rivera-Núñez
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey
| | - Benjamin F. Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Diane Hill
- Rutgers School of Public Affairs and Administration, University-Community Partnerships, Newark, New Jersey
| | - Maria B. Pellerano
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Donita Devance
- Rutgers, the State University of New Jersey, University-Community Partnerships, Newark
| | - Myneka Macenat
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Daniel Lima
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Emmanuel Martinez Alcaraz
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jeanne M. Ferrante
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Emily S. Barrett
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Rutgers Environmental and Occupational Health Sciences Institute, Piscataway, New Jersey
| | - Martin J. Blaser
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Advance Biotechnology and Medicine, New Brunswick, New Jersey
- Department of and Pathology, Rutgers Robert Wood Johnson Medical School, Rutgers Center for Advance Biotechnology and Medicine, New Brunswick, New Jersey
| | - Reynold A. Panettieri
- Rutgers Institute for Translational Medicine and Science, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Shawna V. Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Kaneko M, Inoue M, Okubo M, Furgal AKC, Crabtree BF, Fetters MD. Differences between frequent emergency department users in a secondary rural hospital and a tertiary suburban hospital in central Japan: a prevalence study. BMJ Open 2020; 10:e039030. [PMID: 32900762 PMCID: PMC7478017 DOI: 10.1136/bmjopen-2020-039030] [Citation(s) in RCA: 2] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Although frequent emergency department (ED) use is a global issue, little research has been conducted in a country like Japan where universal health insurance is available. The study aims to (1) document the proportion of ED visits that are by frequent users and (2) describe the differences in characteristics of frequent ED users and other ED users including expenditures between a secondary and a tertiary hospital. DESIGN A prevalence study for a period of 1 year. SETTING A secondary hospital and a tertiary hospital in central Japan. PARTICIPANTS All patients who presented to the EDs. PRIMARY OUTCOME MEASURES We defined frequent ED user as a patient who visited the ED≥5 times/year. The main outcome measures were the proportion of frequent ED users among all ED users and the proportion of healthcare expenditures by the frequent ED users among all ED expenditures. RESULTS Of 25 231 ED visits over 1 year, 134 frequent ED users accounted for 1043 visits-0.66% of all ED users, comprised 4.1% of all ED visits, and accounted for 1.9% of total healthcare expenditures. Median ED visits per one frequent ED user was 7.9. At the patient level, after adjusting for age, gender and receiving public assistance, older age (OR 1.01, 95% CI: 1.00 to 1.02) and receiving public assistance (OR 7.19, 95% CI 2.87 to 18.07) had an association with frequent ED visits. At the visit-level analysis, evaluation by internal medicine (OR 1.27, 95% CI 1.02 to 1.57), psychiatry (OR 124.69, 95% CI 85.89 to 181.01) and obstetrics/gynaecology (OR 2.77, 95% CI 2.09 to 3.67) were associated with frequent ED visits. CONCLUSION The proportion of frequent ED users, of total visits, and of expenditures attributable to them-while still in the low end of the distribution of published ranges-are lower in this study from Japan than in reports from many other countries.
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Affiliation(s)
- Makoto Kaneko
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- Shizuoka Family Medicine Program, Kikugawa, Shizuoka, Japan
| | - Machiko Inoue
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
- Shizuoka Family Medicine Program, Kikugawa, Shizuoka, Japan
| | - Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Allison K Cullen Furgal
- Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Michael D Fetters
- Mixed Methods Program and Department of Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Crabtree BF, Howard J, Miller WL, Cromp D, Hsu C, Coleman K, Austin B, Flinter M, Tuzzio L, Wagner EH. Leading Innovative Practice: Leadership Attributes in LEAP Practices. Milbank Q 2020; 98:399-445. [PMID: 32401386 DOI: 10.1111/1468-0009.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Policy Points An onslaught of policies from the federal government, states, the insurance industry, and professional organizations continually requires primary care practices to make substantial changes; however, ineffective leadership at the practice level can impede the dissemination and scale-up of these policies. The inability of primary care practice leadership to respond to ongoing policy demands has resulted in moral distress and clinician burnout. Investments are needed to develop interventions and educational opportunities that target a broad array of leadership attributes. CONTEXT Over the past several decades, health care in the United States has undergone substantial and rapid change. At the heart of this change is an assumption that a more robust primary care infrastructure helps achieve the quadruple aim of improved care, better patient experience, reduced cost, and improved work life of health care providers. Practice-level leadership is essential to succeed in this rapidly changing environment. Complex adaptive systems theory offers a lens for understanding important leadership attributes. METHODS A review of the literature on leadership from a complex adaptive system perspective identified nine leadership attributes hypothesized to support practice change: motivating others to engage in change, managing abuse of power and social influence, assuring psychological safety, enhancing communication and information sharing, generating a learning organization, instilling a collective mind, cultivating teamwork, fostering emergent leaders, and encouraging boundary spanning. Through a secondary qualitative analysis, we applied these attributes to nine practices ranking high on both a practice learning and leadership scale from the Learning from Effective Ambulatory Practice (LEAP) project to see if and how these attributes manifest in high-performing innovative practices. FINDINGS We found all nine attributes identified from the literature were evident and seemed important during a time of change and innovation. We identified two additional attributes-anticipating the future and developing formal processes-that we found to be important. Complexity science suggests a hypothesized developmental model in which some attributes are foundational and necessary for the emergence of others. CONCLUSIONS Successful primary care practices exhibit a diversity of strong local leadership attributes. To meet the realities of a rapidly changing health care environment, training of current and future primary care leaders needs to be more comprehensive and move beyond motivating others and developing effective teams.
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Affiliation(s)
| | | | | | - DeANN Cromp
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Clarissa Hsu
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Katie Coleman
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Brian Austin
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | | | - Leah Tuzzio
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
| | - Edward H Wagner
- MacColl Center for Health Care Innovation, Kaiser Permanente Washington Health Research Institute
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Margolis KL, Crain AL, Bergdall AR, Beran M, Anderson JP, Solberg LI, O'Connor PJ, Sperl-Hillen JM, Pawloski PA, Ziegenfuss JY, Rehrauer D, Norton C, Haugen P, Green BB, McKinney Z, Kodet A, Appana D, Sharma R, Trower NK, Williams R, Crabtree BF. Design of a pragmatic cluster-randomized trial comparing telehealth care and best practice clinic-based care for uncontrolled high blood pressure. Contemp Clin Trials 2020; 92:105939. [PMID: 31981712 DOI: 10.1016/j.cct.2020.105939] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/16/2020] [Accepted: 01/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Uncontrolled hypertension is the largest single contributor to all-cause and cardiovascular mortality in the U.S. POPULATION Nurse- and pharmacist-led team-based care and telehealth care interventions have been shown to result in large and lasting improvements in blood pressure (BP); however, it is unclear how successfully these can be implemented at scale in real-world settings. It is also uncertain how telehealth interventions impact patient experience compared to traditional clinic-based care. AIMS/OBJECTIVES To compare the effects of two evidence-based blood pressure care strategies in the primary care setting: (1) best-practice clinic-based care and (2) telehealth care with home BP telemonitoring and management by a clinical pharmacist. To evaluate implementation using mixed-methods supported by the RE-AIM framework and Consolidated Framework for Implementation Research. METHODS The design is a cluster-randomized comparative effectiveness pragmatic trial in 21 primary care clinics (9 clinic-based care, 12 telehealth care). Adult patients (age 18-85) with hypertension are enrolled via automated electronic health record (EHR) tools during primary care encounters if BP is elevated to ≥150/95 mmHg at two consecutive visits. The primary outcome is change in systolic BP over 12 months as extracted from the EHR. Secondary outcomes are change in key patient-reported outcomes over 6 months as measured by surveys. Qualitative data are collected at various time points to investigate implementation barriers and help explain intervention effects. CONCLUSION This pragmatic trial aims to inform health systems about the benefits, strengths, and limitations of implementing home BP telemonitoring with pharmacist management for uncontrolled hypertension in real-world primary care settings.
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Affiliation(s)
- Karen L Margolis
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America.
| | - A Lauren Crain
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Anna R Bergdall
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - MarySue Beran
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeffrey P Anderson
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Leif I Solberg
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patrick J O'Connor
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - JoAnn M Sperl-Hillen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Pamala A Pawloski
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Jeanette Y Ziegenfuss
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Dan Rehrauer
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Christine Norton
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Patricia Haugen
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Beverly B Green
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Av, Seattle, WA 98101, United States of America
| | - Zeke McKinney
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Amy Kodet
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Deepika Appana
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Rashmi Sharma
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Nicole K Trower
- HealthPartners Institute, Mailstop 23301A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - RaeAnn Williams
- HealthPartners, Mailstop 31100A, PO Box 1524, Minneapolis, MN 55440-1524, United States of America
| | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ 08901, United States of America
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Crabtree BF, Miller WL, Howard J, Rubinstein EB, Tsui J, Hudson SV, O'Malley D, Ferrante JM, Stange KC. Cancer Survivorship Care Roles for Primary Care Physicians. Ann Fam Med 2020; 18:202-209. [PMID: 32393555 PMCID: PMC7213992 DOI: 10.1370/afm.2498] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/27/2019] [Accepted: 08/13/2019] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Despite a burgeoning population of cancer survivors and pending shortages of oncology services, clear definitions and systematic approaches for engaging primary care in cancer survivorship are lacking. We sought to understand how primary care clinicians perceive their role in delivering care to cancer survivors. METHODS We conducted digitally recorded interviews with 38 clinicians in 14 primary care practices that had national reputations as workforce innovators. Interviews took place during intense case study data collection and explored clinicians' perspectives regarding their role in cancer survivorship care. We analyzed verbatim transcripts using an inductive and iterative immersion-crystallization process. RESULTS Divergent views exist regarding primary care's role in cancer survivor care with a lack of coherence about the concept of survivorship. A few clinicians believed any follow-up care after acute cancer treatment was oncology's responsibility; however, most felt cancer survivor care was within their purview. Some primary care clinicians considered cancer survivors as a distinct population; others felt cancer survivors were like any other patient with a chronic disease. In further interpretative analysis, we discovered a deeply ingrained philosophy of whole-person care that creates a professional identity dilemma for primary care clinicians when faced with rapidly changing specialized knowledge. CONCLUSIONS This study exposes an emerging identity crisis for primary care that goes beyond cancer survivorship care. Facilitated national conversations might help specialists and primary care develop knowledge translation platforms to support the prioritizing, integrating, and personalizing functions of primary care for patients with highly complicated issues requiring specialized knowledge.
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Affiliation(s)
- Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey .,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | | | - Jenna Howard
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Shawna V Hudson
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Denalee O'Malley
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Jeanne M Ferrante
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
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Jimenez ME, Crabtree BF, Veras J, Shelton PA, Mendelsohn AL, Mackie TI, Guevara JP, Pellerano M, Lima D, Hudson SV. Latino Parents' Experiences With Literacy Promotion in Primary Care: Facilitators and Barriers. Acad Pediatr 2020; 20:1177-1183. [PMID: 32795690 PMCID: PMC7655684 DOI: 10.1016/j.acap.2020.08.003] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 07/27/2020] [Accepted: 08/06/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Literacy promotion is a pediatric standard of care in which clinicians provide guidance on shared reading. Latino parents are more likely to hear advice to read with children but are less likely to do so. We sought to understand literacy promotion from the perspective of Latino parents and to identify facilitators and barriers. METHODS We purposively sampled Latino parents who participated in Reach Out and Read (ROR) for a qualitative, semistructured interview study. We identified themes using immersion/crystallization and achieved thematic saturation after 21 interviews. RESULTS Two thirds of participants had less than high school education; half of whom had not completed eighth grade. The mean child age was 16.4 months. Primary facilitators of engagement were advice from a pediatrician during a clinical encounter and receipt of the ROR book. Barriers identified included: 1) parents' perceptions that their children were not developmentally ready and that their children's behavior (eg, activity) indicated they were not interested in shared reading; 2) self-perceived limited literacy and/or English proficiency; 3) parenting demands occurring in the context of poverty; and 4) continued child media use despite advice from pediatricians to choose alternate activities such as shared reading instead. CONCLUSIONS Parent-clinician relationships are central to ROR's impact but clinicians need to pay more attention to factors in a child's broader environment to strengthen literacy promotion. Specifically clinicians should emphasize skill building during the clinical encounter (eg, sharing knowledge about child development and modeling) and work collaboratively with other stakeholders to address poverty-related stressors.
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Affiliation(s)
- Manuel E. Jimenez
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854;,Boggs Center on Developmental Disabilities, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854;,Child Health Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854;,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854;,Children’s Specialized Hospital, 200 Somerset St. New Brunswick, NJ 08901
| | - Benjamin F. Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
| | - Julissa Veras
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
| | - Patricia A. Shelton
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
| | - Alan L. Mendelsohn
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, 462 First Avenue, New York, NY 10016
| | - Thomas I. Mackie
- Rutgers School of Public Health, 683 Hoes Ln W, Piscataway, NJ 08854
| | - James P. Guevara
- Department of Pediatrics, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd. Philadelphia, PA 19104
| | - Maria Pellerano
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
| | - Daniel Lima
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
| | - Shawna V. Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, 675 Hoes Lane Piscataway, NJ 08854
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Tsui J, Howard J, O'Malley D, Miller WL, Hudson SV, Rubinstein EB, Ferrante JM, Bator A, Crabtree BF. Understanding primary care-oncology relationships within a changing healthcare environment. BMC Fam Pract 2019; 20:164. [PMID: 31775653 PMCID: PMC6882058 DOI: 10.1186/s12875-019-1056-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/21/2019] [Indexed: 12/24/2022]
Abstract
Background Management of care transitions from primary care into and out of oncology is critical for optimal care of cancer patients and cancer survivors. There is limited understanding of existing primary care-oncology relationships within the context of the changing health care environment. Methods Through a comparative case study of 14 innovative primary care practices throughout the United States (U.S.), we examined relationships between primary care and oncology settings to identify attributes contributing to strengthened relationships in diverse settings. Field researchers observed practices for 10–12 days, recording fieldnotes and conducting interviews. We created a reduced dataset of all text related to primary care-oncology relationships, and collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process. Results Nine of the 14 practices discussed having either formal or informal primary care-oncology relationships. Nearly all formal primary care-oncology relationships were embedded within healthcare systems. The majority of private, independent practices had more informal relationships between individual primary care physicians and specific oncologists. Practices with formal relationships noted health system infrastructure that facilitates transfer of patient information and timely referrals. Practices with informal relationships described shared commitment, trust, and rapport with specific oncologists. Regardless of relationship type, challenges reported by primary care settings included lack of clarity about roles and responsibilities during cancer treatment and beyond. Conclusions With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate strengths of informal primary care-oncology relationships in addition to formal system driven relationships.
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Affiliation(s)
- Jennifer Tsui
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, 195 Little Albany, New Brunswick, NJ, 08903, USA.
| | - Jenna Howard
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - Denalee O'Malley
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - William L Miller
- Lehigh Valley Health Network, University of South Florida Morsani College of Medicine, 1247 S. Cedar Crest Blvd., Allentown, PA, 18103, USA
| | - Shawna V Hudson
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, 195 Little Albany, New Brunswick, NJ, 08903, USA.,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - Ellen B Rubinstein
- Department of Sociology and Anthropology, North Dakota State University, 428 Minard Hall, 1210 Albrecht Boulevard, Fargo, ND, USA
| | - Jeanne M Ferrante
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - Alicja Bator
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
| | - Benjamin F Crabtree
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, 195 Little Albany, New Brunswick, NJ, 08903, USA.,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, 112 Paterson St, New Brunswick, NJ, 08901, USA
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Miller WL, Rubinstein EB, Howard J, Crabtree BF. Shifting Implementation Science Theory to Empower Primary Care Practices. Ann Fam Med 2019; 17:250-256. [PMID: 31085529 PMCID: PMC6827625 DOI: 10.1370/afm.2353] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 11/12/2018] [Accepted: 12/18/2018] [Indexed: 11/09/2022] Open
Abstract
Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices-along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research-we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.
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Affiliation(s)
- William L Miller
- Lehigh Valley Health Network/University of South Florida Morsani College of Medicine, Allentown, Pennsylvania
| | - Ellen B Rubinstein
- Department of Sociology & Anthropology, North Dakota State Universiry, Fargo, North Dakota
| | - Jenna Howard
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Baron AN, Hemler JR, Sweeney SM, Tate Woodson T, Cuthel A, Crabtree BF, Cohen DJ. Effects of Practice Turnover on Primary Care Quality Improvement Implementation. Am J Med Qual 2019; 35:16-22. [PMID: 31030525 DOI: 10.1177/1062860619844001] [Citation(s) in RCA: 5] [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] [Indexed: 11/17/2022]
Abstract
Primary care practices often engage in quality improvement (QI) in order to stay current and meet quality benchmarks, but the extent to which turnover affects practices' QI ability is not well described. The authors examined qualitative data from practice staff and external facilitators participating in a large-scale QI initiative to understand the relationship between turnover and QI efforts. The examination found turnover can limit practices' ability to engage in QI activities in various ways. When a staff member leaves, remaining staff often absorb additional responsibilities, and QI momentum slows as new staff are trained or existing staff are reengaged. Turnover alters staff dynamics and can create barriers to constructive working relationships and team building. When key practice members leave, they can take with them institutional memory about QI purpose, processes, and long-term vision. Understanding how turnover affects QI may help practices, and those helping them with QI, manage the disruptive effects of turnover.
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Davis SN, O'Malley DM, Bator A, Ohman-Strickland P, Clemow L, Ferrante JM, Crabtree BF, Miller SM, Findley P, Hudson SV. Rationale and design of extended cancer education for longer term survivors (EXCELS): a randomized control trial of 'high touch' vs. 'high tech' cancer survivorship self-management tools in primary care. BMC Cancer 2019; 19:340. [PMID: 30971205 PMCID: PMC6458696 DOI: 10.1186/s12885-019-5531-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/27/2019] [Indexed: 12/20/2022] Open
Abstract
Background Breast, colorectal, and prostate cancer survivors are at increased risk for late and long-term effects post-treatment. The post-treatment phase of care is often poorly coordinated and survivors navigate follow-up care with minimal information or guidance from their healthcare team. This manuscript describes the Extended Cancer Education for Longer-term Survivors (EXCELS) in Primary Care protocol. EXCELS is a randomized controlled trial to test the efficacy of patient-level self-management educational strategies on adherence to preventative health service use and cancer survivorship follow-up guidelines. Methods The EXCELS trial compares four conditions: (1) EXCELS-website (e.g., a mobile-optimized technology platform); (2) EXCELS-health coaching; (3) EXCELS-website and health coaching; and (4) a print booklet. Approximately 480 breast, colorectal, and prostate survivors will be recruited through the New Jersey Primary Care Research Network (NJPCRN) and New Jersey State Cancer Registry (NJSCR). Eligible survivors (diagnosed stages 1–3) must have completed active treatment, access to a phone and a computer, smartphone or tablet with internet access, and be able to speak and read English. Patient assessments occur at baseline, 6, 12, and 18 months. The primary outcomes are increased engagement in preventive health services and monitoring for cancer recurrence and treatment-related late effects. Discussion The EXCELS trial is the first to test cancer survivorship educational self-management interventions for cancer survivors in a primary care context. Findings from this trial will inform successful implementation and engagement strategies for longer-term, post-treatment cancer survivors managed in primary care settings. Trial registration Registered August 1, 2017 at ClinicalTrials.gov, trial # NCT03233555.
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Affiliation(s)
- Stacy N Davis
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers School of Public Health, Health Behavior, Society and Policy, Piscataway, NJ, USA.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Denalee M O'Malley
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA
| | - Alicja Bator
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA
| | - Pamela Ohman-Strickland
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers School of Public Health, Health Behavior, Society and Policy, Piscataway, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA.,Rutgers School of Public Health, Biostatistics, Piscataway, NJ, USA
| | - Lynn Clemow
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA
| | - Jeanne M Ferrante
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA
| | - Benjamin F Crabtree
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA.,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA.,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA
| | | | | | - Shawna V Hudson
- Rutgers Biomedical and Health Sciences, Rutgers, the State University of New Jersey, 112 Paterson Street, Room 446, New Brunswick, NJ, 08901, USA. .,Rutgers School of Public Health, Health Behavior, Society and Policy, Piscataway, NJ, USA. .,Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA. .,Rutgers Robert Wood Johnson Medical School, Department of Family, Medicine and Community Health, New Brunswick, NJ, USA.
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Jimenez ME, Hudson SV, Lima D, Mendelsohn AL, Pellerano M, Crabtree BF. Perspectives on shared reading among a sample of Latino parents. Child Care Health Dev 2019; 45:292-299. [PMID: 30471139 DOI: 10.1111/cch.12634] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/14/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Paediatric professionals promote shared reading to facilitate school readiness, yet relatively few studies examine how parents from underserved communities consider this issue in their daily lives. We sought to understand shared reading within the broader context of parenting among Latino parents. METHODS We conducted in-depth interviews, purposively sampling Spanish-speaking, Latina mothers of children aged ≤3 years from an urban Federally Qualified Health Center. Interviews were recorded, transcribed, and analysed iteratively. We allowed themes to emerge from data rather than impose an a priori framework. We sought disconfirming evidence within interviews and collected additional data to ensure no new themes were identified (saturation). RESULTS We achieved saturation after 12 interviews. The median child age was 1.4 years. We identified four major themes: (a) All participants reported engaging in literacy promoting activities such as conversations, storytelling, play, and singing even if they did not read to their children daily. (b) Parents' attitudes regarding early learning and development influenced the extent to which parents engaged in shared reading with their child. (c) Participants described feelings that they ought to read daily with their children but were not and cited a variety of barriers. (d) Parents who engaged in frequent shared reading described it as a joyful and relaxed experience; parents who did not engage in shared reading described reading as instructing children or engaging in drills (e.g., teaching letters). CONCLUSION Urban, Latina mothers who did not read regularly with their children nonetheless recognized its importance suggesting that existing programmes have raised awareness even among underserved families. Refinement of messaging may be needed to move past raising awareness to facilitating shared reading for some parents.
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Affiliation(s)
- Manuel E Jimenez
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey.,The Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey.,Child Health Institute of New Jersey, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey.,Boggs Center on Developmental Disabilities, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Children's Specialized Hospital, New Brunswick, New Jersey
| | - Shawna V Hudson
- The Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey
| | - Daniel Lima
- The Department of Pediatrics, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey
| | - Alan L Mendelsohn
- Department of Pediatrics, New York University School of Medicine/Bellevue Hospital Center, New York, New York
| | - Maria Pellerano
- The Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey
| | - Benjamin F Crabtree
- The Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School New Brunswick, New Jersey
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Ono SS, Crabtree BF, Hemler JR, Balasubramanian BA, Edwards ST, Green LA, Kaufman A, Solberg LI, Miller WL, Woodson TT, Sweeney SM, Cohen DJ. Taking Innovation To Scale In Primary Care Practices: The Functions Of Health Care Extension. Health Aff (Millwood) 2019; 37:222-230. [PMID: 29401016 DOI: 10.1377/hlthaff.2017.1100] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health care extension is an approach to providing external support to primary care practices with the aim of diffusing innovation. EvidenceNOW was launched to rapidly disseminate and implement evidence-based guidelines for cardiovascular preventive care in the primary care setting. Seven regional grantee cooperatives provided the foundational elements of health care extension-technological and quality improvement support, practice capacity building, and linking with community resources-to more than two hundred primary care practices in each region. This article describes how the cooperatives varied in their approaches to extension and provides early empirical evidence that health care extension is a feasible and potentially useful approach for providing quality improvement support to primary care practices. With investment, health care extension may be an effective platform for federal and state quality improvement efforts to create economies of scale and provide practices with more robust and coordinated support services.
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Affiliation(s)
- Sarah S Ono
- Sarah S. Ono ( ) is an assistant professor in the Department of Family Medicine at Oregon Health & Science University and an investigator in the Center to Improve Veteran Involvement in Care, Veterans Affairs (VA) Portland Health Care System, both in Portland
| | - Benjamin F Crabtree
- Benjamin F. Crabtree is a professor in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School, in New Brunswick, New Jersey
| | - Jennifer R Hemler
- Jennifer R. Hemler is a research associate in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School
| | - Bijal A Balasubramanian
- Bijal A. Balasubramanian is an associate professor in the Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, in Texas
| | - Samuel T Edwards
- Samuel T. Edwards is an assistant research professor in the Department of Family Medicine and an assistant professor of medicine at Oregon Health & Science University and a staff physician in the Section of General Internal Medicine, VA Portland Health Care System
| | - Larry A Green
- Larry A. Green is a professor of family medicine and the Epperson-Zorn Chair for Innovation in Family Medicine at the University of Colorado Denver, in Aurora
| | - Arthur Kaufman
- Arthur Kaufman is distinguished professor in the Department of Family and Community Medicine and vice chancellor for community health at the University of New Mexico, in Albuquerque
| | - Leif I Solberg
- Leif I. Solberg is a senior adviser and director for care improvement research at HealthPartners Institute, in Minneapolis, Minnesota
| | - William L Miller
- William L. Miller is chair emeritus in the Department of Family Medicine, Lehigh Valley Health Network, in Allentown, Pennsylvania
| | - Tanisha Tate Woodson
- Tanisha Tate Woodson is a senior research associate in the Department of Family Medicine, Oregon Health & Science University
| | - Shannon M Sweeney
- Shannon M. Sweeney is a research associate in the Department of Family Medicine and Community Health, Research Division, Rutgers Robert Wood Johnson Medical School
| | - Deborah J Cohen
- Deborah J. Cohen is a professor and vice chair of research in the Department of Family Medicine at Oregon Health & Science University
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Jimenez ME, Hudson SV, Lima D, Crabtree BF. Engaging a Community Leader to Enhance Preparation for In-Depth Interviews With Community Members. Qual Health Res 2019; 29:270-278. [PMID: 30101661 DOI: 10.1177/1049732318792848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In-depth interviews allow for rich exploration of stakeholders' experiences. Preparation for in-depth interviews generally consists of literature reviews and researchers' review of their own culture and understanding of a topic. We supplemented these strategies with serial "ethnographic interviews" with a single community leader to enhance our preparation for community-based in-depth interviews with Latina, immigrant, Spanish-speaking mothers and to facilitate stakeholder engagement in a research project. After an extensive literature review, we conducted a series of four 1-hour interviews with a key informant in preparation for individual in-depth interviews with 12 parents. The ethnographic interviews with the community leader provided insight into environmental context, cultural categories, and stakeholder priorities, which helped shape the research question, in-depth interview guide, sampling strategy, and interpretive analytic process. We found that ethnographic interviews can provide critical insights for preparing in-depth interview guides and can enhance the information gained while facilitating meaningful stakeholder engagement.
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Affiliation(s)
- Manuel E Jimenez
- 1 Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
- 2 Children's Specialized Hospital, New Brunswick, New Jersey, USA
| | - Shawna V Hudson
- 1 Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Daniel Lima
- 1 Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Benjamin F Crabtree
- 1 Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Tsui J, Hudson SV, Rubinstein EB, Howard J, Hicks E, Kieber-Emmons A, Bator A, Lee HS, Ferrante J, Crabtree BF. A mixed-methods analysis of the capacity of the Patient-Centered Medical Home to implement care coordination services for cancer survivors. Transl Behav Med 2018; 8:319-327. [PMID: 29800396 DOI: 10.1093/tbm/ibx059] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
There are currently 15.5 million cancer survivors in USA who are increasingly relying on primary care providers for their care. Patient-Centered Medical Homes (PCMHs) have the potential to meet the unique needs of cancer survivors; but, few studies have examined PCMH attributes as potential resources for delivering survivorship care. This study assesses the current care coordination infrastructure in advanced PCMHs, known to be innovative, and explores their capacity to provide cancer survivorship care. We conducted comparative case studies of a purposive sample (n = 9) of PCMHs to examine current care coordination infrastructure and capacity through a mixed- methods analysis. Data included qualitative interviews, quantitative surveys, and fieldnotes collected during 10- to 12-day onsite observations at each practice. Case studies included practices in five states with diverse business models and settings. Eight of the nine practices had National Committee for Quality Assurance Level 3 PCMH recognition. No practices had implemented a systematic approach to cancer survivorship care. We found all practices had a range of electronic population health management tools, care coordinator roles in place for chronic conditions, and strategies or protocols for tracking and managing complex disease groups. We identified potential capacity, as well as barriers, to provide cancer survivorship care using existing care coordination infrastructure developed for other chronic conditions. This existing infrastructure suggests the potential to translate care coordination elements within primary care settings to accelerate the implementation of systematic survivorship care.
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Affiliation(s)
- Jennifer Tsui
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Shawna V Hudson
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA.,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Ellen B Rubinstein
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Jenna Howard
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Elisabeth Hicks
- Department of Family Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | - Autumn Kieber-Emmons
- Lehigh Valley Health Network/University of Southern Florida Morsani School of Medicine, Allentown, PA, USA
| | - Alicja Bator
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Heather S Lee
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Jeanne Ferrante
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
| | - Benjamin F Crabtree
- Division of Population Science, Rutgers Cancer Institute of New Jersey, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA.,Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, Rutgers, the State University of New Jersey, New Brunswick, NJ, USA
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Tsui J, Howard J, Miller WL, O'Malley DM, Hudson SV, Rubinstein E, Bator A, Crabtree BF. Opportunities for improving cancer care management through primary care-oncology relationships. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.30_suppl.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
80 Background: Improvements in the management of care transitions between primary care and oncology are critical for achieving optimal care quality and outcomes for cancer patients and survivors. We examine relationships between innovative PC practices and oncologists to inform and strengthen PC-oncology interfaces in diverse healthcare settings. Methods: Comparative case studies of 14 innovative PC practices throughout the United States examined strategies for providing cancer survivorship care. Field researchers observed each practice for 10-12 days, recording fieldnotes and conducting key informant and formal, semi-structured interviews with clinicians and staff. We extracted all data related to PC-oncology relationships and then collaboratively identified patterns to characterize these relationships through an inductive “immersion/crystallization” analysis process. Results: Nine of the 14 practices discussed either formal or informal PC-oncology relationships. Nearly all practices with existing formal PC-oncology relationships were embedded within healthcare systems. Private, independent practices had more informal relationships between individual PC physicians and specific oncologists. Practices with formal relationships noted ease of communication and transfer of patient information, timeliness in patient referrals, and direct access to oncologists; while practices with informal relationships noted the benefits of having close engagement with specific oncologists. Regardless of relationship type, remaining challenges include lack of clarity about roles during cancer treatment and beyond. Conclusions: With the rapid transformation of U.S. healthcare towards system ownership of primary care practices, efforts are needed to integrate the strengths of both formal and informal PC-oncology relationships to improve care for cancer patients and survivors.
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Affiliation(s)
- Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Jenna Howard
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Denalee M. O'Malley
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ
| | | | - Ellen Rubinstein
- Department of Family Medicine, University of Michigan,, Ann Arbor, MI
| | - Alicja Bator
- Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
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Russell GM, Miller WL, Gunn JM, Levesque JF, Harris MF, Hogg WE, Scott CM, Advocat JR, Halma L, Chase SM, Crabtree BF. Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries. Fam Pract 2018; 35:276-284. [PMID: 29069376 PMCID: PMC5965082 DOI: 10.1093/fampra/cmx095] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. OBJECTIVE To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. METHODS An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. RESULTS Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. CONCLUSION The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.
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Affiliation(s)
- Grant M Russell
- Southern Academic Primary Care Research Unit, School of Primary and Allied Health Care, Monash University, Clayton, Australia
| | - William L Miller
- Department of Family Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Jane M Gunn
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia.,Bureau of Health Information, Chatswood, NSW, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia
| | - William E Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Cathie M Scott
- Alberta Centre for Child, Family and Community Research, Edmonton, Canada
| | - Jenny R Advocat
- Southern Academic Primary Care Research Unit, School of Primary Health Care, Monash University, Clayton, Australia
| | - Lisa Halma
- Zone Analytics and Reporting Services, Alberta Health Services, Edmonton, Canada
| | - Sabrina M Chase
- Rutgers Biomedical and Health Sciences (RBHS), Rutgers School of Nursing, Rutgers University, New Brunswick, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
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Crabtree BF, Miller WL, Gunn JM, Hogg WE, Scott CM, Levesque JF, Harris MF, Chase SM, Advocat JR, Halma LM, Russell GM. Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach. Fam Pract 2018; 35:266-275. [PMID: 29069335 PMCID: PMC5965090 DOI: 10.1093/fampra/cmx091] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. OBJECTIVE To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. METHODS We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. RESULTS CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. CONCLUSIONS The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.
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Affiliation(s)
- Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, USA
| | - William L Miller
- Department of Family Medicine; Lehigh Valley Health Network, Allentown, USA
| | - Jane M Gunn
- Department of General Practice and Primary Health Care, University of Melbourne, Melbourne, Australia
| | - William E Hogg
- C.T. Lamont Primary Health Care Research Centre, Bruyère Research Institute, Ottawa, Canada.,Department of Family Medicine, University of Ottawa, Ottawa, Canada
| | - Cathie M Scott
- Alberta Centre for Child, Family and Community Research, Edmonton, Canada
| | - Jean-Frederic Levesque
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia.,Bureau of Health Information, Chatswood, Australia
| | - Mark F Harris
- Centre for Primary Health Care and Equity, University of New South Wales Australia, Sydney, Australia
| | - Sabrina M Chase
- Rutgers Biomedical and Health Sciences (RBHS), Rutgers School of Nursing, Rutgers University, New Brunswick, USA
| | - Jenny R Advocat
- Southern Academic Primary Care Research Unit, School of Primary and Allied Health Care, Monash University, Clayton, Australia
| | - Lisa M Halma
- Zone Analytics and Reporting Services, Alberta Health Services, Edmonton, Canada
| | - Grant M Russell
- Southern Academic Primary Care Research Unity, School of Primary and Allied Health Care, Monash University, Clayton, Australia
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Wu JP, Damschroder LJ, Fetters MD, Zikmund-Fisher BJ, Crabtree BF, Hudson SV, Ruffin MT, Fucinari J, Kang M, Taichman LS, Creswell JW. A Web-Based Decision Tool to Improve Contraceptive Counseling for Women With Chronic Medical Conditions: Protocol For a Mixed Methods Implementation Study. JMIR Res Protoc 2018; 7:e107. [PMID: 29669707 PMCID: PMC5932336 DOI: 10.2196/resprot.9249] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/18/2017] [Accepted: 02/05/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Women with chronic medical conditions, such as diabetes and hypertension, have a higher risk of pregnancy-related complications compared with women without medical conditions and should be offered contraception if desired. Although evidence based guidelines for contraceptive selection in the presence of medical conditions are available via the United States Medical Eligibility Criteria (US MEC), these guidelines are underutilized. Research also supports the use of decision tools to promote shared decision making between patients and providers during contraceptive counseling. OBJECTIVE The overall goal of the MiHealth, MiChoice project is to design and implement a theory-driven, Web-based tool that incorporates the US MEC (provider-level intervention) within the vehicle of a contraceptive decision tool for women with chronic medical conditions (patient-level intervention) in community-based primary care settings (practice-level intervention). This will be a 3-phase study that includes a predesign phase, a design phase, and a testing phase in a randomized controlled trial. This study protocol describes phase 1 and aim 1, which is to determine patient-, provider-, and practice-level factors that are relevant to the design and implementation of the contraceptive decision tool. METHODS This is a mixed methods implementation study. To customize the delivery of the US MEC in the decision tool, we selected high-priority constructs from the Consolidated Framework for Implementation Research and the Theoretical Domains Framework to drive data collection and analysis at the practice and provider level, respectively. A conceptual model that incorporates constructs from the transtheoretical model and the health beliefs model undergirds patient-level data collection and analysis and will inform customization of the decision tool for this population. We will recruit 6 community-based primary care practices and conduct quantitative surveys and semistructured qualitative interviews with women who have chronic medical conditions, their primary care providers (PCPs), and clinic staff, as well as field observations of practice activities. Quantitative survey data will be summarized with simple descriptive statistics and relationships between participant characteristics and contraceptive recommendations (for PCPs), and current contraceptive use (for patients) will be examined using Fisher exact test. We will conduct thematic analysis of qualitative data from interviews and field observations. The integration of data will occur by comparing, contrasting, and synthesizing qualitative and quantitative findings to inform the future development and implementation of the intervention. RESULTS We are currently enrolling practices and anticipate study completion in 15 months. CONCLUSIONS This protocol describes the first phase of a multiphase mixed methods study to develop and implement a Web-based decision tool that is customized to meet the needs of women with chronic medical conditions in primary care settings. Study findings will promote contraceptive counseling via shared decision making and reflect evidence-based guidelines for contraceptive selection. TRIAL REGISTRATION ClinicalTrials.gov NCT03153644; https://clinicaltrials.gov/ct2/show/NCT03153644 (Archived by WebCite at http://www.webcitation.org/6yUkA5lK8).
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Affiliation(s)
- Justine P Wu
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | | | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Brian J Zikmund-Fisher
- Department of Health Behavior and Health Education, University of Michigan, Ann Arbor, MI, United States.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Shawna V Hudson
- Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Mack T Ruffin
- Department of Family and Community Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, United States
| | - Juliana Fucinari
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Minji Kang
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - L Susan Taichman
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
| | - John W Creswell
- Department of Family Medicine, University of Michigan, Ann Arbor, MI, United States
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Balasubramanian BA, Marino M, Cohen DJ, Ward RL, Preston A, Springer RJ, Lindner SR, Edwards S, McConnell KJ, Crabtree BF, Miller WL, Stange KC, Solberg LI. Use of Quality Improvement Strategies Among Small to Medium-Size US Primary Care Practices. Ann Fam Med 2018; 16:S35-S43. [PMID: 29632224 PMCID: PMC5891312 DOI: 10.1370/afm.2172] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/07/2017] [Accepted: 11/15/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Improving primary care quality is a national priority, but little is known about the extent to which small to medium-size practices use quality improvement (QI) strategies to improve care. We examined variations in use of QI strategies among 1,181 small to medium-size primary care practices engaged in a national initiative spanning 12 US states to improve quality of care for heart health and assessed factors associated with those variations. METHODS In this cross-sectional study, practice characteristics were assessed by surveying practice leaders. Practice use of QI strategies was measured by the validated Change Process Capability Questionnaire (CPCQ) Strategies Scale (scores range from -28 to 28, with higher scores indicating more use of QI strategies). Multivariable linear regression was used to examine the association between practice characteristics and the CPCQ strategies score. RESULTS The mean CPCQ strategies score was 9.1 (SD = 12.2). Practices that participated in accountable care organizations and those that had someone in the practice to configure clinical quality reports from electronic health records (EHRs), had produced quality reports, or had discussed clinical quality data during meetings had higher CPCQ strategies scores. Health system-owned practices and those experiencing major disruptive changes, such as implementing a new EHR system or clinician turnover, had lower CPCQ strategies scores. CONCLUSION There is substantial variation in the use of QI strategies among small to medium-size primary care practices across 12 US states. Findings suggest that practices may need external support to strengthen their ability to do QI and to be prepared for new payment and delivery models.
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Affiliation(s)
- Bijal A Balasubramanian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Miguel Marino
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Deborah J Cohen
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rikki L Ward
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Alex Preston
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Rachel J Springer
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Stephan R Lindner
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Samuel Edwards
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - K John McConnell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Benjamin F Crabtree
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - William L Miller
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Kurt C Stange
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
| | - Leif I Solberg
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health in Dallas, Dallas, Texas (Balasubramanian, Ward, Preston); Department of Family Medicine, Oregon Health & Science University, Portland, Oregon (Marino, Cohen, Springer, Edwards); School of Public Health, Oregon Health & Science University - Portland State University, Portland, Oregon (Marino); Center for Health Systems Effectiveness, and Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon (Lindner, McConnell); Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey (Crabtree); Department of Family Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania (Miller); Center for Community Health Integration, Departments of Family Medicine and Community Health, Population and Quantitative Health Sciences, and Sociology, Case Western Reserve University, Cleveland, Ohio (Stange); HealthPartners Institute, Minneapolis, Minnesota (Solberg); Section of General Internal Medicine, Veterans Affairs Portland Health Care System, Portland, Oregon (Edwards)
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Kieber-Emmons A, Crabtree BF, Miller W. A new mixed methods approach to uncover multi-level barriers and facilitators of cancer survivorship. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.7_suppl.36] [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: 11/20/2022] Open
Abstract
36 Background: As healthcare becomes increasingly complex, research needs to take into account multi-level interactions that contribute to public health issues. One such area ripe for multi-level investigation is cancer survivorship care, illuminated in the 2006 Lost in Transition Institute of Medicine report on cancer survivors. We have developed a novel method that aims to understand barriers and facilitators of cancer survivorship from multiple levels, including community factors, medical system features, and policy and environmental influences. Methods: Our method, focused Rapid Assessment Process (fRAP), utilizes mixed methods at multiple levels to better understand cancer survivorship care with a primary care lens. fRAP begins with Geographic Information Systems (GIS) to map variables relevant to cancer survivorship care, such as cancer mortality rates, insurance coverage, and oncology and primary care provider sites. Qualitative participant observation and semi-structured interviews of informants from each level are then undertaken to better understand how cancer survivorship care is delivered within a county or census tract. Lastly, modifiable contextual factors from all levels are identified, as potential future environmental policy change targets. Results: As a development and pilot of our novel fRAP, we have designed, tested, revised and retested our methods over the last 3 years within the framework of two national grant-funded studies on cancer survivorship in primary care. Preliminary modifiable factors of interest affecting cancer survivorship care have been identified for future dissemination. The newest and current iteration of our methods has focused on utilizing GIS specifically to identify hot spots of cervical cancer mortality disparities in order to provide the richest contextual environment for subsequent qualitative inquiry into survivorship care. Conclusions: fRAP is a novel mixed method that has potential to identify modifiable barriers and facilitators of high-quality cancer survivorship care nationally, and may aid in policy improvements in health and healthcare delivery for survivors.
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Goodwin MA, Stange KC, Zyzanski SJ, Crabtree BF, Borawski EA, Flocke SA. The Hawthorne effect in direct observation research with physicians and patients. J Eval Clin Pract 2017; 23:1322-1328. [PMID: 28752911 PMCID: PMC5741487 DOI: 10.1111/jep.12781] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content. METHODS Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation. RESULTS Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer. CONCLUSIONS In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients.
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Affiliation(s)
- Meredith A Goodwin
- Department of Family Medicine and Community Health, Case Western Reserve University, Cleveland, Ohio, USA
| | - Kurt C Stange
- Department of Family Medicine and Community Health, Department of Epidemiology and Biostatistics, Department of Sociology, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Stephen J Zyzanski
- Department of Family Medicine and Community Health, Department of Epidemiology and Biostatistics, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Benjamin F Crabtree
- Department of Family Medicine, Rutgers University, New Brunswick, New Jersey, USA
| | - Elaine A Borawski
- Prevention Research Center for Healthy Neighborhoods and Department of Epidemiology and Biostatistics, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Susan A Flocke
- Department of Family Medicine and Community Health, Department of Epidemiology and Biostatistics, Prevention Research Center for Healthy Neighborhoods and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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Rubinstein EB, Miller WL, Hudson SV, Howard J, O'Malley D, Tsui J, Lee HS, Bator A, Crabtree BF. Cancer Survivorship Care in Advanced Primary Care Practices: A Qualitative Study of Challenges and Opportunities. JAMA Intern Med 2017; 177:1726-1732. [PMID: 28973067 PMCID: PMC5820731 DOI: 10.1001/jamainternmed.2017.4747] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
IMPORTANCE Despite a decade of effort by national stakeholders to bring cancer survivorship to the forefront of primary care, there is little evidence to suggest that primary care has begun to integrate comprehensive services to manage the care of long-term cancer survivors. OBJECTIVE To explain why primary care has not begun to integrate comprehensive cancer survivorship services. DESIGN, SETTING, AND PARTICIPANTS Comparative case study of 12 advanced primary care practices in the United States recruited from March 2015 to February 2017. Practices were selected from a national registry of 151 workforce innovators compiled for the Robert Wood Johnson Foundation. Practices were recruited to include diversity in policy context and organizational structure. Researchers conducted 10 to 12 days of ethnographic data collection in each practice, including interviews with practice personnel and patient pathways with cancer survivors. Fieldnotes, transcripts, and practice documents were analyzed within and across cases to identify salient themes. MAIN OUTCOMES AND MEASURES Description of cancer survivorship care delivery in advanced patient-centered medical homes, including identification of barriers and promotional factors related to that care. RESULTS The 12 practices came from multiple states and policy contexts and had a mix of clinicians trained in family or internal medicine. All but 3 were recognized as National Committee on Quality Assurance level 3 patient-centered medical homes. None of the practices provided any type of comprehensive cancer survivorship services. Three interdependent explanatory factors emerged: the absence of a recognized, distinct clinical category of survivorship in primary care; a lack of actionable information to treat this patient population; and current information systems unable to support survivorship care. CONCLUSIONS AND RELEVANCE To increase the potential for primary care transformation efforts to integrate survivorship services into routine care, survivorship must become a recognized clinical category with actionable care plans supported by a functional information system infrastructure.
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Affiliation(s)
- Ellen B Rubinstein
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,now with Department of Family Medicine, University of Michigan, Ann Arbor
| | | | - Shawna V Hudson
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jenna Howard
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Denalee O'Malley
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Jennifer Tsui
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Heather Sophia Lee
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Alicja Bator
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Benjamin F Crabtree
- Research Division, Department of Family Medicine and Community Health, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Sweeney SM, Hall JD, Ono SS, Gordon L, Cameron D, Hemler J, Solberg LI, Crabtree BF, Cohen DJ. Recruiting Practices for Change Initiatives Is Hard: Findings From EvidenceNOW. Am J Med Qual 2017; 33:246-252. [PMID: 28868889 DOI: 10.1177/1062860617728791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Engaging primary care practices in initiatives designed to enhance quality, reduce costs, and promote safety is challenging as practices are already participating in numerous projects and mandated programs designed to improve care delivery and quality. Recruiters must expand their recruitment tools to engage today's practices in quality improvement. Using grant proposals, online diaries, observational site visits, and interviews with key stakeholders, the authors identify successful practice recruitment strategies in the EvidenceNOW initiative, which aimed to recruit approximately 1500 small- to medium-sized primary care practices. Recruiters learned they needed to articulate how participation in EvidenceNOW aligned with other initiatives and could help practices succeed with federal and state initiatives, recognition programs, and existing or future payment requirements. Recruiters, initiative leaders, and funders must now consider how their efforts align with ongoing initiatives to successfully recruit and engage practices, ease practice burden, and encourage participation in efforts that support practice transformation.
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Affiliation(s)
| | | | - Sarah S Ono
- 2 Oregon Health & Science University, Portland, OR.,3 VA Portland Health Care System, Portland, OR
| | - Leah Gordon
- 2 Oregon Health & Science University, Portland, OR
| | | | | | - Leif I Solberg
- 4 HealthPartners Institute for Education and Research, Minneapolis, MN
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Stapleton JL, Crabtree BF. "These people, you just guide them until they become these people": learning to become a frequent indoor tanner. BMC Psychol 2017; 5:11. [PMID: 28376928 PMCID: PMC5379755 DOI: 10.1186/s40359-017-0181-4] [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: 11/09/2016] [Accepted: 03/24/2017] [Indexed: 11/16/2022] Open
Abstract
Background Many young women experiment with using indoor tanning beds with some becoming regular users. There is a dearth of research focused on factors related to the development of regular tanning. This study was designed to gain an in-depth understanding of the experiences of a regular indoor tanning bed user for the purpose of discovering working hypotheses related to the development of this behavior. The article thesis is that initial interactions with tanning salon employees transmit insider knowledge that serves to encourage the regular use of indoor tanning beyond experimentation. Methods We used Spradley’s ethnographic interviewing technique to conduct six iterative interviews with a key informant who was an active indoor tanning bed user and former salon employee. The research was completed in the United States in 2015. Results The informant described her experiences as a salon employee including her interactions with salon patrons. The informant was trained as a salon employee to talk about tanning as a complex process that requires multiple salon visits to achieve desired results and to develop rapport with salon patrons to be viewed as an important source of guidance and advice. In the informant’s experience, indoor tanning users who viewed tanning as a complex process and felt connected to salon employees were more receptive to purchasing larger amounts of bulk tanning sessions and committing to purchasing salon memberships. Conclusions Findings provide insights into our understanding of the development of regular tanning behavior and we propose working hypotheses about this behavior to be examined in future research. There are also implications for policy makers to reduce excessive tanning behaviors including considering point-of-sale regulations that limit sales techniques of salon employees and pricing restrictions.
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Affiliation(s)
- Jerod L Stapleton
- Rutgers, The State University of New Jersey, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, Room 5570, New Brunswick, NJ, 08903, USA.
| | - Benjamin F Crabtree
- Rutgers, The State University of New Jersey, RWJ-Family Medicine-Research, Institute for Health, Health Care Policy and Aging Research (IFH), 112 Paterson Street, New Brunswick, NJ, 08901, USA
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O'Malley DM, Davis SN, Crabtree BF, Hudson SV. Primary care physicians experiences of caring for cancer survivors: Toward developing a primary care-responsive cancer survivorship research agenda. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.5_suppl.97] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
97 Background: Understanding of the ecology of primary care can inform efforts that aim to build primary care capacity to address cancer survivorship issues. This study describes the experiences of primary care physicians (PCPs) delivering care to cancer survivors. Methods: Semi-structured in-depth interviews were conducted with PCPs (n=30) across two NCI-funded studies of cancer survivorship in primary care. PCPs were recruited from primary care practices enrolled in a qualitative case study of cancer survivorship in patient centered medical homes (R01 CA176545; n=21) and from a sample recruited for the formative development of a primary care mHealth and health coaching interventions for cancer survivors (R01 CA176838; n=9). Interviews averaged 30 minutes, were audio-recorded and transcribed verbatim. A multi-step immersion/crystallization approach was used to identify emergent themes using Atlas.ti. Results: PCPs stated that their role in cancer survivorship care varies widely and is often shaped by patient characteristics. These characteristics include: patient expectations of the PCPs role; the patient’s ability to provide clinical details about their cancer and its treatment; and the status of patient relationship with cancer treatment team. PCPs described having incomplete information and recounted experiences of cancer survivors presenting for visits motivated by fear of disease recurrence. PCPs described the tensions around having to make decisions about further additional testing versus offering support about recurrence of fears with incomplete clinical information. PCPs also expressed a need for basic clinical information and surveillance plans to be integrated into existing systems of care (e.g. electronic medical record systems and registries), citing immunization schedules as a potential model. Conclusions: The lack of clinical information to inform cancer survivors’ care remains a critical challenge to PCPs. Survivorship care plans are a proposed strategy to rectify informational deficits; however, further evaluation of how effectively care plans integrate into primary care systems and processes are needed.
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Affiliation(s)
- Denalee M. O'Malley
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ
| | | | - Benjamin F Crabtree
- Rutgers Robert Wood Johnson Medical School, Department of Family Medicine and Community Health, New Brunswick, NJ
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Wagner EH, Flinter M, Hsu C, Cromp D, Austin BT, Etz R, Crabtree BF, Ladden MD. Effective team-based primary care: observations from innovative practices. BMC Fam Pract 2017; 18:13. [PMID: 28148227 PMCID: PMC5289007 DOI: 10.1186/s12875-017-0590-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/22/2017] [Indexed: 11/22/2022]
Abstract
Background Team-based care is now recognized as an essential feature of high quality primary care, but there is limited empiric evidence to guide practice transformation. The purpose of this paper is to describe advances in the configuration and deployment of practice teams based on in-depth study of 30 primary care practices viewed as innovators in team-based care. Methods As part of LEAP, a national program of the Robert Wood Johnson Foundation, primary care experts nominated 227 innovative primary care practices. We selected 30 practices for intensive study through review of practice descriptive and performance data. Each practice hosted a 3-day site visit between August, 2012 and September, 2013, where specific advances in team configuration and roles were noted. Advances were identified by site visitors and confirmed at a meeting involving representatives from each of the 30 practices. Results LEAP practices have expanded the roles of existing staff and added new personnel to provide the person power and skills needed to perform the tasks and functions expected of a patient-centered medical home (PCMH). LEAP practice teams generally include a rich array of staff, especially registered nurses (RNs), behavioral health specialists, and lay health workers. Most LEAP practices organize their staff into core teams, which are built around partnerships between providers and specific Medical Assistants (MAs), and often include registered nurses (RNs) and others such as health coaches or receptionists. MAs, RNs, and other staff are heavily involved in the planning and delivery of preventive and chronic illness care. The care of more complex patients is supported by behavioral health specialists, RN care managers, and pharmacists. Standing orders and protocols enable staff to act independently. Conclusions The 30 LEAP practices engage health professional and lay staff in patient care to the maximum extent, which enables the practices to meet the expectations of a PCMH and helps free up providers to focus on tasks that only they can perform. Electronic supplementary material The online version of this article (doi:10.1186/s12875-017-0590-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Edward H Wagner
- MacColl Center for Health Care Innovation, Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA, 98101, USA.
| | | | - Clarissa Hsu
- Center for Community Health and Evaluation, Group Health Research Institute, Seattle, WA, USA
| | - DeAnn Cromp
- Center for Community Health and Evaluation, Group Health Research Institute, Seattle, WA, USA
| | - Brian T Austin
- MacColl Center for Health Care Innovation, Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA, 98101, USA
| | - Rebecca Etz
- Department of Family Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Benjamin F Crabtree
- Department of Family Medicine and Community Health, Rutgers-Robert Wood Johnson Medical School, Piscataway Township, NJ, USA
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Bergdall AR, Sperl-Hillen JM, O'Connor PJ, Asche SE, Crabtree BF, Smith EA, Nyober RA, Dehmer SP, Maciosek MV, Pawlowski PA, Trower NK, Margolis KL. Qualitative Data from a Trial of Home Blood Pressure Telemonitoring and Pharmacist Management (Hyperlink). J Patient Cent Res Rev 2016. [DOI: 10.17294/2330-0698.1308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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