Partnering for Integrated Care: A Learning Collaborative for Primary Care and Oral Health Teams.

PURPOSE: The Teaming and Integrating for Smiles and Health (TISH) Learning Collaborative was developed to help health care organizations accelerate progress in integrating delivery of oral and primary care. By providing expert support and a structure for testing change, the project aimed to improve the early detection of hypertension in the dental setting and of gingivitis in the primary care setting, and to increase the rate of bidirectional referrals between oral and primary care partners. We report its outcomes. METHODS: A total of 17 primary and oral health care teams were recruited to participate in biweekly virtual calls over 3 months. Participants tested changes to their models of care through Plan-Do-Study-Act cycles between calls. Sites tracked the percentages of patients screened and referred, completed the TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) and Interprofessional Assessment questionnaires, and provided qualitative feedback and updates in storyboard presentations. RESULTS: On average, with implementation of the TISH Learning Collaborative, sites displayed a nonrandom improvement in the percentages of patients screened for hypertension, referred for hypertension, referred to primary care, and referred for gingivitis. Gingivitis screening and referral to oral health care were not markedly improved. Qualitative responses indicated that teams made progress in screening and referral workflows, improved communication between medical and dental partners, and furthered understanding of the connection between primary care and oral care among staff and patients. CONCLUSIONS: The TISH project is evidence that a virtual Learning Collaborative is an accessible and productive avenue to improve interprofessional education, further primary care and oral partnerships, and achieve practical progress in integrated care.

Evaluating a patient safety learning laboratory to create an interdisciplinary ecosystem for health care innovation.

BACKGROUND: In response to the complexity, challenges, and slow pace of innovation, health care organizations are adopting interdisciplinary team approaches. Systems engineering, which is oriented to creating new, scalable processes that perform with higher reliability and lower costs, holds promise for driving innovation in the face of challenges to team performance. A patient safety learning laboratory (lab) can be an essential aspect of fostering interdisciplinary team innovation across multiple projects and organizations by creating an ecosystem focused on deploying systems engineering methods to accomplish process redesign. PURPOSE: We sought to identify the role and activities of a learning ecosystem that support interdisciplinary team innovation through evaluation of a patient safety learning lab. METHODS: Our study included three participating learning lab project teams. We applied a mixed-methods approach using a convergent design that combined data from qualitative interviews of team members conducted as teams neared the completion of their redesign projects, as well as evaluation questionnaires administered throughout the 4-year learning lab. RESULTS: Our results build on learning theories by showing that successful learning ecosystems continually create alignment between interdisciplinary teams' activities, organizational context, and innovation project objectives. The study identified four types of alignment, interpersonal/interprofessional, informational, structural, and processual, and supporting activities for alignment to occur. CONCLUSION: Interdisciplinary learning ecosystems have the potential to foster health care improvement and innovation through alignment of team activities, project goals, and organizational contexts. PRACTICE IMPLICATIONS: This study applies to interdisciplinary teams tackling multilevel system challenges in their health care organization and suggests that the work of such teams benefits from the four types of alignment. Alignment on all four dimensions may yield best results.

Burnout Among Missouri Primary Care Clinicians in 2021: Roadmap for Recovery?

Rates of burnout among clinicians have been exacerbated by the COVID-19 (COVID)pandemic. A survey of Missouri primary care professionals at federally qualified health centers was conducted during a COVID surge in August 2021 to assess burnout, stress, and job satisfaction as well as if respondents had sought assistance for burnout or attended resiliency training. Despite respondents reporting rates of burnout (56%) that exceed those reported nationally (48%), only 17% sought help for burnout. Most (81%) had not attended resiliency training; of those who did, 16% said sessions "make me feel less alone," while an equivalent number found sessions not useful, identifying an absence of resources within their organization. Comments focused on the need for dedicated time to receive support, including time to seek assistance during working hours, time to take breaks, and time for self-care. The data suggest one path forward to remediate burnout: provide the workforce with time to access support.

Genetic suppression of IKK2/NF-κB in astrocytes inhibits neuroinflammation and reduces neuronal loss in the MPTP-Probenecid model of Parkinson's disease.

Neuroinflammatory activation of glia is considered a pathological hallmark of Parkinson's disease (PD) and is seen in both human PD patients and in animal models of PD; however, the relative contributions of these cell types, especially astrocytes, to the progression of disease is not fully understood. The transcription factor, nuclear factor kappa B (NFκB), is an important regulator of inflammatory gene expression in glia and is activated by multiple cellular stress signals through the kinase complex, IKK2. We sought to determine the role of NFκB in modulating inflammatory activation of astrocytes in a model of PD by generating a conditional knockout mouse (hGfapcre/Ikbk2F/F) in which IKK2 is specifically deleted in astrocytes. Measurements of IKK2 revealed a 70% deletion rate of IKK2 within astrocytes, as compared to littermate controls (Ikbk2F/F). Use of this mouse in a subacute, progressive model of PD through exposure to 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine and probenecid (MPTPp) revealed significant protection in exposed mice to direct and progressive loss of dopaminergic neurons in the substantia nigra (SN). hGfapcre/Ikbk2F/F mice were also protected against MPTPp-induced loss in motor activity, loss of striatal proteins, and genomic alterations in nigral NFκB gene expression, but were not protected from loss of striatal catecholamines. Neuroprotection in hGfapcre/Ikbk2F/F mice was associated with inhibition of MPTPp-induced astrocytic expression of inflammatory genes and protection against nitrosative stress and apoptosis in neurons. These data indicate that deletion of IKK2 within astrocytes is neuroprotective in the MPTPp model of PD and suggests that reactive astrocytes directly contribute the potentiation of dopaminergic pathology.

The Nurr1 Ligand,1,1-bis(3'-Indolyl)-1-(p-Chlorophenyl)Methane, Modulates Glial Reactivity and Is Neuroprotective in MPTP-Induced Parkinsonism.

The orphan nuclear receptor Nurr1 (also called nuclear receptor-4A2) regulates inflammatory gene expression in glial cells, as well as genes associated with homeostatic and trophic function in dopaminergic neurons. Despite these known functions of Nurr1, an endogenous ligand has not been discovered. We postulated that the activation of Nurr1 would suppress the activation of glia and thereby protect against loss of dopamine (DA) neurons after subacute lesioning with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Our previous studies have shown that a synthetic Nurr1 ligand, 1,1-bis(3'-indolyl)-1-(p-chlorophenyl)methane (C-DIM12), suppresses inflammatory gene expression in primary astrocytes and induces a dopaminergic phenotype in neurons. Pharmacokinetic analysis of C-DIM12 in mice by liquid chromatography-mass spectrometry demonstrated that approximately three times more compound concentrated in the brain than in plasma. Mice treated with four doses of MPTP + probenecid over 14 days were monitored for neurobehavioral function, loss of dopaminergic neurons, and glial activation. C-DIM12 protected against the loss of DA neurons in the substantia nigra pars compacta and DA terminals in the striatum, maintained a ramified phenotype in microglia, and suppressed activation of astrocytes. In vitro reporter assays demonstrated that C-DIM12 was an effective activator of Nurr1 transcription in neuronal cell lines. Computational modeling of C-DIM12 binding to the three-dimensional structure of human Nurr1 identified a high-affinity binding interaction with Nurr1 at the coactivator domain. Taken together, these data suggest that C-DIM12 is an activator of Nurr1 that suppresses glial activation and neuronal loss in vivo after treatment with MPTP, and that this receptor could be an efficacious target for disease modification in individuals with Parkinson's disease and related disorders.

Primary Care Collaboration to Improve Diagnosis and Screening for Colorectal Cancer.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer death, reducible by screening and early diagnosis, yet many patients fail to receive recommended screening. As part of an academic improvement collaborative, 25 primary care practices worked to improve CRC screening and diagnosis. METHODS: The project featured triannual learning sessions, monthly conference calls, practice coach support, and monthly reporting. The project phases included literature review and interviews with national leaders/organizations, development of driver diagrams to identify key factors and change ideas, project launch and practice team planning, and a practice improvement phase. RESULTS: The project activities included (1) inventory of barriers and best practices, (2) driver diagram to drive improvements, (3) list of changes to try, (4) compilation of lessons learned, and (5) five key changes to optimize screening and follow-up. Practices leveraged prior transformation efforts to track patients for screening and follow-up during and between office visits. By mapping processes, testing changes, and collecting data, sites targeted opportunities to improve quality, safety, efficiency, and patient and care team experience. Successful change interventions centered around partnering with gastroenterology, engaging leadership, leveraging registries and health information technology, promoting alternative screening options, and partnering with and supporting patients. Several practices achieved improvement in screening rates, while others demonstrated no change from baseline during the 10-month testing and implementation phase (July 2014-April 2015). CONCLUSION: The collaborative effectively engaged teams in a broad set of process improvements with key lessons learned related to barriers, information technology challenges, outreach challenges/strategies, and importance of stakeholder and patient engagement.

Single dose intralesional doxycycline foam infusion promotes bone growth and resolution of an odontoid aneurysmal bone cyst.

Background: Aneurysmal bone cysts (ABCs) are locally invasive bone tumors that most commonly arise in long bone metaphyses, the vertebral column, and pelvis, often presenting in the second decade of life. ABCs can be treated with resection, radiation, arterial embolization, and intralesional curettage. More recently intralesional doxycycline foam injections, which appear to act through the inhibition of matrix metalloproteinases and angiogenesis, have been used successfully, although multiple treatments are often required with this approach. Case Description: A 13-year-old male with an incidentally discovered ABC filling much of the odontoid process but not violating the native odontoid cortex was treated with a single intralesional doxycycline foam injection delivered through a transoral approach with an excellent radiographic result. After placing a Crowe-Davis retractor, a transoral exposure of the odontoid process was performed with neuronavigation guidance. A fluoroscopy-guided Jamshidi needle biopsy was performed and via the needle doxycycline foam (2 mL 50 mg/mL doxycycline, 2 mL 25% albumin, and 1 mL Isovue 370 mixed with 5 mL of air) was infused, filling the cystic cavities of the odontoid process. The patient tolerated the operation well. Two months postoperatively, a computed tomography (CT) scan demonstrated a decrease in the size of the lesion with substantial new bone formation. Repeat CT at 6 months showed no residual cystic lucency, formation of dense new bone, and only minimal irregularity of the cortex at the prior needle biopsy site. Conclusion: This case illustrates that the use of doxycycline foam can be an excellent option when managing ABCs that cannot be resected without incurring significant morbidity.

Using Rapid-Cycle Change to Improve COVID-19 Vaccination Strategy in Primary Care.

During the COVID-19 pandemic, misinformation and distrust exacerbated disparities in vaccination rates by race and ethnicity throughout the United States. Primary care, public health systems, and community health centers have shifted their vaccination outreach strategies toward these disparate, unvaccinated populations. To support primary care, we developed the SAVE Sprint model for implementing rapid-cycle change to improve vaccination rates by overcoming community outreach barriers and workforce limitations. Participants were recruited for the 10-week SAVE Sprint program through partnerships with the National Association of Community Health Centers (NACHC) and the Resilient American Communities (RAC) Initiative. The majority of the participants were from community health centers. Data were evaluated during the program through progress reports and surveys, and interviews conducted three months post-intervention were recorded, coded, and analyzed. The SAVE Sprint model of rapid-cycle change exceeded participants' expectations and led to improvements in patient education and vaccination among their vulnerable populations. Participants reported building new skills and identifying strategies for targeting specific populations during a public health emergency. However, participants reported that planning for rapid-pace change and trust-building with community partners prior to a health care crisis is preferable and would make navigating an emergency easier.

Lessons Learned in Implementing a Chronic Opioid Therapy Management System.

OBJECTIVES: Opioid misuse has resulted in significant morbidity and mortality in the United States, and safer opioid use represents an important challenge in the primary care setting. This article describes a research collaborative of health service researchers, systems engineers, and clinicians seeking to improve processes for safer chronic opioid therapy management in an academic primary care center. We present implementation results and lessons learned along with an intervention toolkit that others may consider using within their organization. METHODS: Using iterative improvement lifecycles and systems engineering principles, we developed a risk-based workflow model for patients on chronic opioids. Two key safe opioid use process metrics-percent of patients with recent opioid treatment agreements and urine drug tests-were identified, and processes to improve these measures were designed, tested, and implemented. Focus groups were conducted after the conclusion of implementation, with barriers and lessons learned identified via thematic analysis. RESULTS: Initial surveys revealed a lack of knowledge regarding resources available to patients and prescribers in the primary care clinic. In addition, 18 clinicians (69%) reported largely "inheriting" (rather than initiating) their chronic opioid therapy patients. We tracked 68 patients over a 4-year period. Although process measures improved, full adherence was not achieved for the entire population. Barriers included team structure, the evolving opioid environment, and surveillance challenges, along with disruptions resulting from the 2019 novel coronavirus. CONCLUSIONS: Safe primary care opioid prescribing requires ongoing monitoring and management in a complex environment. The application of a risk-based approach is possible but requires adaptability and redundancies to be reliable.

Moving the needle on primary care burnout: Using a driver diagram to accelerate impact.

Prior to the COVID-19 pandemic, studies demonstrated an alarming prevalence of burnout in primary care. In the midst of the pandemic, primary care clinician wellbeing deteriorated and burnout rates increased, yet many organizational efforts to reduce burnout were put on hold due to the urgency of the pandemic. In this article, we present the "Reducing Burnout Driver Diagram" as a tool that clinical leaders and policy makers can use to address and mitigate primary care clinician burnout.

Patient engagement in system redesign teams: a process of social identity.

PURPOSE: Studies demonstrate how patient roles in system redesign teams reflect a continuum of involvement and influence. This research shows the process by which patients move through this continuum and effectively engage within redesign projects. DESIGN/METHODOLOGY/APPROACH: The authors studied members of redesign teams, consisting of 5-10 members: clinicians, systems engineers, health system staff and patient(s), from three health systems working on separate projects in a patient safety learning lab. Weekly team meetings were observed, January 2016-April 2018, 17 semi-structured interviews were conducted and findings through a patient focus group were refined. Grounded theory was used to analyze field notes and transcripts. FINDINGS: Results show how the social identity process enables patients to move through stages in a patient engagement continuum (informant, partner and active change agent). Initially, patient and team member perceptions of the patient's role influence their respective behaviors (activating, directing, framing and sharing). Subsequently, patient and team member behaviors influence patient contributions on the team, which can redefine patient and team member perceptions of the patient's role. ORIGINALITY/VALUE: As health systems grow increasingly complex and become more interested in responding to patient expectations, understanding how to effectively engage patients on redesign teams gains importance. This research investigates how and why patient engagement on redesign teams changes over time and what makes different types of patient roles valuable for team objectives. Findings have implications for how redesign teams can better prepare, anticipate and support the changing role of engaged patients.

Annual Primary Care 2030 Convening: Creating an Enabling Ecosystem for Person-Centered Primary Healthcare Models to Achieve Universal Health Coverage in Low- and Middle-Income Countries.

Background: The 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana reaffirm the highest level of political commitment by United Nations Member States to achieve access to health services and primary healthcare for all. Both documents emphasize the importance of person-centered care in both healthcare services and systems design. However, there is limited consensus on how to build a strong primary healthcare system to achieve these goals. Methods: We convened a diverse group of global stakeholders for a high-level dialogue on how to create a person-centered primary healthcare system, using the country examples of the Republic of Kenya and the Socialist Republic of Vietnam. We focused our discussion on four themes to enable the creation of person-centered primary healthcare systems in Kenya and Vietnam: (1) strengthened community, person and patient engagement in subnational and national decision making; (2) improved service delivery; (3) impactful use of innovation and technology; and (4) meaningful and timely use of measurement and data. Findings: Here, we present a summary of our convening's proceedings, with specific insights on how to enable a person-centered primary healthcare system within each of these four domains. Conclusions: Following the 2019 United Nations General Assembly High-Level Meeting on Universal Health Coverage and the 2018 Declaration of Astana, there is high-level commitment and global consensus that a person-centered approach is necessary to achieve high-quality primary healthcare and universal health coverage. We offer our recommendations to the global community to catalyze further discourse and inform policy-making and program development on the path to Universal Health Coverage by 2030.

First report of a toxic Nodularia spumigena (Nostocales/ Cyanobacteria) bloom in sub-tropical Australia. II. Bioaccumulation of nodularin in isolated populations of mullet (Mugilidae).

Fish collected after a mass mortality at an artificial lake in south-east Queensland, Australia, were examined for the presence of nodularin as the lake had earlier been affected by a Nodularia bloom. Methanol extracts of muscle, liver, peritoneal and stomach contents were analysed by HPLC and tandem mass spectrometry; histological examination was conducted on livers from captured mullet. Livers of sea mullet (Mugil cephalus) involved in the fish kill contained high concentrations of nodularin (median 43.6 mg/kg, range 40.8-47.8 mg/kg dry weight; n = 3) and the toxin was also present in muscle tissue (median 44.0 µg/kg, range 32.3-56.8 µg/kg dry weight). Livers of fish occupying higher trophic levels accumulated much lower concentrations. Mullet captured from the lake 10 months later were also found to have high hepatic nodularin levels. DNA sequencing of mullet specimens revealed two species inhabiting the study lake: M. cephalus and an unidentified mugilid. The two mullet species appear to differ in their exposure and/or uptake of nodularin, with M. cephalus demonstrating higher tissue concentrations. The feeding ecology of mullet would appear to explain the unusual capacity of these fish to concentrate nodularin in their livers; these findings may have public health implications for mullet fisheries and aquaculture production where toxic cyanobacteria blooms affect source waters. This report incorporates a systematic review of the literature on nodularin measured in edible fish, shellfish and crustaceans.