Implementing Enhanced Recovery Pathways: A Qualitative Study of Factors That Distinguished Higher Performing Hospitals.

OBJECTIVE: The aim of this study was to explore barriers and facilitators to implementing enhanced recovery pathways, with a focus on identifying factors that distinguished hospitals achieving greater levels of implementation success. BACKGROUND: Despite the clinical effectiveness of enhanced recovery pathways, the implementation of these complex interventions varies widely. While there is a growing list of contextual factors that may affect implementation, little is known about which factors distinguish between higher and lower levels of implementation success. METHODS: We conducted in-depth interviews with 168 perioperative leaders, clinicians, and staff from 8 US hospitals participating in the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Guided by the Consolidated Framework for Implementation Research, we coded interview transcripts and conducted a thematic analysis of implementation barriers and facilitators. We also rated the perceived effect of factors on different levels of implementation success, as measured by hospitals' adherence with 9 process measures over time. RESULTS: Across all hospitals, factors with a consistently positive effect on implementation included information-sharing practices and the implementation processes of planning and engaging. Consistently negative factors included the complexity of the pathway itself, hospitals' infrastructure, and the implementation process of "executing" (particularly in altering electronic health record systems). Hospitals with the greatest improvement in process measure adherence were distinguished by clinicians' positive knowledge and beliefs about pathways and strong leadership support from both clinicians and executives. CONCLUSION: We draw upon diverse perspectives from across the perioperative continuum of care to qualitatively describe implementation factors most strongly associated with successful implementation of enhanced recovery pathways.

Love over gold and mind over matter? Identifying capabilities that preserve medical assistants' sustainable employability.

BACKGROUND: Medical assistants (MAs) are crucial for affordable, high-quality primary care, but what motivates this low-wage occupational group to stay in their job remains underexplored. This paper identifies the work aspects that MAs value ("capabilities"), and how they affect sustainable employability, which refers to employees' long-term ability to function and remain in their job. METHODS: We used structural equation modelling to assess how capabilities relate to four outcomes among MAs: burnout, job satisfaction, intention to quit, and experiencing work as meaningful. RESULTS: We find that earning a good income, developing knowledge and skills, and having meaningful relationships at work relate to the outcomes. Meaningful relationships represent a stronger predictor than salary for one's intention to quit. CONCLUSIONS: Competitive salaries are necessary but not sufficient to motivate low-wage health care workers like MAs to stay in their job. Health care leaders and managers should also structure work so that MAs can foster meaningful relationships with others as well as develop competencies.

Social networks of people with serious mental illness who smoke: potential role in a smoking cessation intervention.

BACKGROUND: Smoking is a major contributor to morbidity and mortality among individuals with serious mental illness (SMI) and social networks may play an important role in smoking behaviors. AIMS: Our objectives were to (1) describe the network characteristics of adults with SMI who smoke tobacco (2) explore whether network attributes were associated with nicotine dependence. METHODS: We performed a secondary analysis of baseline data from a tobacco smoking cessation intervention trial among 192 participants with SMI. A subgroup (n = 75) completed questions on the characteristics of their social network members. The network characteristics included network composition (e.g. proportion who smoke) and network structure (e.g. density of connections between members). We used multilevel models to examine associations with nicotine dependence. RESULTS: Participant characteristics included: a mean age 50 years, 49% women, 48% Black, and 41% primary diagnosis of schizophrenia/schizoaffective disorder. The median personal network proportion of active smokers was 22%, active quitters 0%, and non-smokers 53%. The density of ties between actively smoking network members was greater than between non-smoking members (55% vs 43%, p = .02). Proportion of network smokers was not associated with nicotine dependence. CONCLUSIONS: We identified potential social network challenges and assets to smoking cessation and implications for network interventions among individuals with SMI.

Overcoming barriers to implementing new guideline-directed therapies for chronic kidney disease.

For the first time in many years, guideline-directed drug therapies have emerged that offer substantial cardiorenal benefits, improved quality of life and longevity in patients with chronic kidney disease (CKD) and type 2 diabetes. These treatment options include sodium-glucose cotransporter-2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists and glucagon-like peptide-1 receptor agonists. However, despite compelling evidence from multiple clinical trials, their uptake has been slow in routine clinical practice, reminiscent of the historical evolution of angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use. The delay in implementation of these evidence-based therapies highlights the many challenges to optimal CKD care, including: (i) clinical inertia; (ii) low CKD awareness; (iii) suboptimal kidney disease education among patients and providers; (iv) lack of patient and community engagement; (v) multimorbidity and polypharmacy; (vi) challenges in the primary care setting; (vii) fragmented CKD care; (viii) disparities in underserved populations; (ix) lack of public policy focused on health equity; and (x) high drug prices. These barriers to optimal cardiorenal outcomes can be ameliorated by a multifaceted approach, using the Chronic Care Model framework, to include patient and provider education, patient self-management programs, shared decision making, electronic clinical decision support tools, quality improvement initiatives, clear practice guidelines, multidisciplinary and collaborative care, provider accountability, and robust health information technology. It is incumbent on the global kidney community to take on a multidimensional perspective of CKD care by addressing patient-, community-, provider-, healthcare system- and policy-level barriers.

A systematic review of respect between acute care nurses and physicians.

BACKGROUND: Interprofessional collaboration between nurses and physicians has become an essential part of patient care, which, when lacking, can lead to well-known challenges. One possible explanation for ineffective nurse-physician collaboration is a lack of respect. PURPOSE: This review aims to enhance our understanding of the role of respect in work between nurses and physicians by synthesizing evidence about the conceptualization of respect, its mechanisms and outcomes, and its origins. METHODS: We performed a PRISMA-guided systematic literature review across five databases and reviewed 28 empirical studies about respect between nurses and physicians in acute care settings. FINDINGS: Research about respect between nurses and physicians varied in its conceptualization of respect in terms of its nature (as an attitude or behavior), its target (respect for individuals or groups), and its object (respect for task-relevant capabilities or human rights). The greatest convergence was on respect's object; the majority of studies focused on respect for task-relevant capabilities. The work reviewed offered insights into respect's potential mechanisms (attention and civility), outcomes (e.g., collaboration, patient outcomes, and provider outcomes such as job satisfaction), and origins (e.g., professional status and competence)-the latter suggesting how respect might be generated, developed, and maintained. PRACTICE IMPLICATIONS: Our review highlights a need to appreciate how respect for task-relevant capabilities relates to respect for human rights and what fosters each to avoid rewarding only one while hoping for both, allowing leaders to cultivate more effective nurse-physician collaborations and better patient and provider outcomes.

Scaling Interventions to Manage Chronic Disease: Innovative Methods at the Intersection of Health Policy Research and Implementation Science.

Policy implementation is a key component of scaling effective chronic disease prevention and management interventions. Policy can support scale-up by mandating or incentivizing intervention adoption, but enacting a policy is only the first step. Fully implementing a policy designed to facilitate implementation of health interventions often requires a range of accompanying implementation structures, like health IT systems, and implementation strategies, like training. Decision makers need to know what policies can support intervention adoption and how to implement those policies, but to date research on policy implementation is limited and innovative methodological approaches are needed. In December 2021, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness and the Johns Hopkins Center for Mental Health and Addiction Policy convened a forum of research experts to discuss approaches for studying policy implementation. In this report, we summarize the ideas that came out of the forum. First, we describe a motivating example focused on an Affordable Care Act Medicaid health home waiver policy used by some US states to support scale-up of an evidence-based integrated care model shown in clinical trials to improve cardiovascular care for people with serious mental illness. Second, we define key policy implementation components including structures, strategies, and outcomes. Third, we provide an overview of descriptive, predictive and associational, and causal approaches that can be used to study policy implementation. We conclude with discussion of priorities for methodological innovations in policy implementation research, with three key areas identified by forum experts: effect modification methods for making causal inferences about how policies' effects on outcomes vary based on implementation structures/strategies; causal mediation approaches for studying policy implementation mechanisms; and characterizing uncertainty in systems science models. We conclude with discussion of overarching methods considerations for studying policy implementation, including measurement of policy implementation, strategies for studying the role of context in policy implementation, and the importance of considering when establishing causality is the goal of policy implementation research.

Being "low on the totem pole": What makes work worthwhile for medical assistants in an era of primary care transformation.

BACKGROUND: Primary care is undergoing a transformation to become increasingly team-based and multidisciplinary. The medical assistant (MA) is considered a core occupation in the primary care workforce, yet existing studies suggest problematic rates and costs of MA turnover. PURPOSE: We investigated what MAs perceive their occupation to be like and what they value in it to understand how to promote sustainable employability, a concept that is concerned with an employee's ability to function and remain in their job in the long term. APPROACH: We used a case of a large, integrated health system in the United States that practices team-based care and has an MA career development program. We conducted semistructured interviews with 16 MAs in this system and performed an inductive analysis of themes. RESULTS: Our analysis revealed four themes on what MAs value at work: (a) using clinical competence, (b) being a multiskilled resource for clinic operations, (c) building meaningful relationships with patients and coworkers, and (d) being recognized for occupational contributions. MAs perceived scope-of-practice regulations as limiting their use of clinical competence. They also perceived task similarity with nurses in the primary care setting and expressed a relative lack of performance recognition. CONCLUSION: Some of the practice changes that enable primary care transformation may hinder MAs' ability to attain their work values. Extant views on sustainable employability assume a high bar for intrinsic values but are limited when applied to low-wage health care workers in team-based environments. PRACTICE IMPLICATIONS: Efforts to effectively employ and retain MAs should consider proactive communications on scope-of-practice regulations, work redesign to emphasize clinical competence, and the establishment of greater recognition and respect among MAs and nurses.

A double-edged sword: The effects of social network ties on job satisfaction in primary care organizations.

BACKGROUND: Social ties between health care workers may be an important driver of job satisfaction; however, research on this topic is limited. PURPOSE: We used social network methods to collect data describing two types of social ties, (a) instrumental ties (i.e., exchange of advice that enables work) and (b) expressive ties (i.e., exchange of social support), and related those ties to workers' job satisfaction. METHODOLOGY: We surveyed 456 clinicians and staff at 23 primary care practices about their social networks and workplace attitudes. We used multivariable linear regression to estimate the relationship between an individual's job satisfaction and two network properties: (a) eigenvector centrality (a measure of the importance of an individual in a network) and (b) ego network density (a measure of the cohesiveness of an individual's network). We examined this relationship for both instrumental and expressive ties. RESULTS: Individuals who were more central in the expressive network were less satisfied in their job, b = -0.40 (0.19), p < .05, whereas individuals who had denser instrumental networks were more satisfied in their job, b = 0.49 (0.21), p < .05. CONCLUSION: Workplace relationships affect worker well-being. Centrality in an expressive network may require greater emotional labor, increasing workers' risk for job dissatisfaction. On the other hand, a dense instrumental network may promote job satisfaction by strengthening workers' access to full information, supporting competence and confidence. PRACTICE IMPLICATIONS: Efforts to increase job satisfaction should consider both the positive and negative effects of social networks on workers' sense of well-being.

Assessing Nephrology Fellows' Skills in Communicating About Kidney Replacement Therapy and Kidney Biopsy: A Multicenter Clinical Simulation Study on Breaking Bad News.

RATIONALE & OBJECTIVE: Interpersonal communication skills and professionalism competencies are difficult to assess among nephrology trainees. We developed a formative "Breaking Bad News" simulation and implemented a study in which nephrology fellows were assessed with regard to their skills in providing counseling to simulated patients confronting the need for kidney replacement therapy (KRT) or kidney biopsy. STUDY DESIGN: Observational study of communication competency in the setting of preparing for KRT for kidney failure, for KRT for acute kidney injury (AKI), or for kidney biopsy. SETTING & PARTICIPANTS: 58 first- and second-year nephrology fellows assessed during 71 clinical evaluation sessions at 8 training programs who participated in an objective structured clinical examination of simulated patients in 2017 and 2018. PREDICTORS: Fellowship training year and clinical scenario. OUTCOME: Primary outcome was the composite score for the "overall rating" item on the Essential Elements of Communication-Global Rating Scale 2005 (EEC-GRS), as assessed by simulated patients. Secondary outcomes were the score for EEC-GRS "overall rating" item for each scenario, score < 3 for any EEC-GRS item, Mini-Clinical Examination Exercise (Mini-CEX) score < 3 on at least 1 item (as assessed by faculty), and faculty and fellow satisfaction with simulation exercise (via a survey they completed). ANALYTICAL APPROACH: Nonparametric tests of hypothesis comparing performance by fellowship year (primary goal) and scenario. RESULTS: Composite scores for EEC-GRS overall rating item were not significantly different between fellowship years (P = 0.2). Only 4 of 71 fellow evaluations had an unsatisfactory score for the EEC-GRS overall rating item on any scenario. On Mini-CEX, 17% scored < 3 on at least 1 item in the kidney failure scenario; 37% and 53% scored < 3 on at least 1 item in the AKI and kidney biopsy scenarios, respectively. In the survey, 96% of fellows and 100% of faculty reported the learning objectives were met and rated the experience good or better in 3 survey rating questions. LIMITATIONS: Relatively brief time for interactions; limited familiarity with and training of simulated patients in use of EEC-GRS. CONCLUSIONS: The fellows scored highly on the EEC-GRS regardless of their training year, suggesting interpersonal communication competency is achieved early in training. The fellows did better with the kidney failure scenario than with the AKI and kidney biopsy scenarios. Structured simulated clinical examinations may be useful to inform curricular choices and may be a valuable assessment tool for communication and professionalism.

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy.

BACKGROUND: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation's unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). SUMMARY: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Collaboration in Health Care and Social Service Networks for Older Adults: Association With Health Care Utilization Measures.

BACKGROUND: Services targeting social determinants of health-such as income support, housing, and nutrition-have been shown to improve health outcomes and reduce health care costs for older adults. Nevertheless, evidence on the properties of effective collaborative networks across health care and social services sectors is limited. OBJECTIVES: The main objectives of this study were to identify features of collaborative networks of health care and social services organizations associated with avoidable health care use and spending for older adults. RESEARCH DESIGN: Through a 2017 survey, we collected data on collaborative ties among health care and social service organizations in 20 US communities with either high or low performance on avoidable health care use and spending for Medicare beneficiaries. Six types of ties were measured: any collaboration, referrals, sharing information, cosponsoring projects, financial contracts, and joint needs assessment. We examined how characteristics of collaborative networks were associated with performance. RESULTS: High-performing networks were distinguished from low-performing networks by 2 features: (1) health care organizations occupied positions of significantly greater centrality (P<0.01), and (2) subnetworks of cosponsorship ties were more cohesive, as measured by centralization (P=0.05) and density (P=0.06). Across all networks, Area Agencies on Aging were more centrally positioned than any other type of organization (P<0.05). CONCLUSIONS: Cross-sector engagement by health care organizations, particularly development of deeper types of collaborative ties such as cosponsorship, may reduce preventable health care use and spending. Efforts to foster effective partnerships could leverage the Area Agencies on Aging, which are already positioned as network brokers.

Sharing innovations to enhance renal fellow education in dialysis.

Dialysis care is an integral part of the practice of nephrology. Despite this, education of fellows in providing dialysis often remains rudimentary, relying on a combination of didactics and learning through experience. This runs the risk of training nephrologists who can provide dialysis care without truly being experts on the subject. In this article, a collection of novel or innovative teaching methods is presented that are meant to provide training programs with additional tools with which to improve the training of their fellows in dialysis.

Pre-End-Stage Renal Disease Care and Early Survival among Incident Dialysis Patients in the US Military Health System.

BACKGROUND: Previous reports showed an increased early mortality after chronic dialysis initiation among the end-stage renal disease (ESRD) population. We hypothesized that ESRD patients in the Military Health System (MHS) would have greater access to pre-ESRD care and hence better survival rates during this early high-risk period. METHODS: In this retrospective cohort study, using the US Renal Data System database, we identified 1,256,640 patients initiated on chronic dialysis from January 2, 2004 through December 31, 2014, from which a bootstrap sample of 3,984 non-MHS incident dialysis patients were compared with 996 MHS patients. We assessed care by a nephrologist and dietitian, erythropoietin administration, and vascular access use at dialysis initiation as well as all-cause mortality as outcome variables. RESULTS: MHS patients were significantly more likely to have had pre-ESRD nephrology care (adjusted OR [aOR] 2.9; 95% CI 2.3-3.7) and arteriovenous fistula used at dialysis initiation (aOR 2.2; 95% CI 1.7-2.7). Crude mortality rates peaked between the 4th and the 8th week for both cohorts but were reduced among MHS patients. The baseline adjusted Cox model showed significantly lower death rates among MHS vs. non-MHS patients at 6, 9, and 12 months. This survival advantage among MHS patients was attenuated after further adjustment for pre-ESRD nephrology care and dialysis vascular access. CONCLUSIONS: MHS patients had improved survival within the first 12 months compared to the general ESRD population, which may be explained in part by differences in pre-ESRD nephrology care and vascular access types.

Implementation of nephrology subspecialty curricular milestones.

Beginning in the 2014-2015 training year, the US Accreditation Council for Graduate Medical Education (ACGME) required that nephrology Clinical Competency Committees assess fellows' progress toward 23 subcompetency "context nonspecific" internal medicine subspecialty milestones. Fellows' advancement toward the "ready for unsupervised practice" target milestone now is tracked in each of the 6 competencies: Patient Care, Medical Knowledge, Professionalism, Interpersonal Communication Skills, Practice-Based Learning and Improvement, and Systems-Based Practice. Nephrology program directors and subspecialty societies must define nephrology-specific "curricular milestones," mapped to the nonspecific ACGME milestones. Although the ACGME goal is to produce data that can discriminate between successful and underperforming training programs, the approach is at risk to produce biased, inaccurate, and unhelpful information. We map the ACGME internal medicine subspecialty milestones to our previously published nephrology-specific milestone schema and describe entrustable professional activities and other objective assessment tools that inform milestone decisions. Mapping our schema onto the ACGME subspecialty milestone reporting form allows comparison with the ACGME subspecialty milestones and the curricular milestones developed by the American Society of Nephrology Program Directors. Clinical Competency Committees may easily adapt and directly translate milestone decisions reached using our schema onto the ACGME internal medicine subspecialty competency milestone-reporting format.

Survival Disparity of African American Versus Non-African American Patients With ESRD Due to SLE.

BACKGROUND: A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non-African American patients with LN-caused ESRD, compared with other causes. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Using the US Renal Data System database, we identified 12,352 patients with LN-caused ESRD among 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31, 2010. PREDICTORS: Baseline demographics and comorbid conditions, Hispanic ethnicity, socioeconomic factors (employment status, Medicare/Medicaid insurance, and area-level median household income based on zip code as obtained from the 2000 US census), and kidney transplantation as a time-dependent variable. OUTCOME: All-cause mortality. MEASUREMENTS: Multivariable Cox and competing-risk regressions. RESULTS: Mean duration of follow-up in the LN-caused ESRD and other-cause ESRD cohorts were 6.24±4.20 (SD) and 4.06±3.61 years, respectively. 6,106 patients with LN-caused ESRD (49.43%) and 853,762 patients with other-cause ESRD (76.24%) died during the study period (P<0.001). Patients with LN-caused ESRD were significantly younger (mean age, 39.92 years) and more likely women (81.65%) and African American (48.13%) than those with other-cause ESRD. In the fully adjusted multivariable Cox regression model, African American (vs non-African American) patients with LN-caused ESRD had significantly increased risk of death at age 18 to 30 years (adjusted HR, 1.43; 95% CI, 1.24-1.65) and at age 31 to 40 years (adjusted HR, 1.17; 95% CI, 1.02-1.34). Among patients with other-cause ESRD, African Americans were at significantly increased risk at age 18 to 30 years (adjusted HR, 1.17; 95% CI, 1.11-1.22). LIMITATIONS: We used zip code-based median household income as a surrogate for patient income. Residual socioeconomic confounders may exist. CONCLUSIONS: African Americans are at significantly increased risk of death compared with non-African Americans with LN-caused ESRD at age 18 to 40 years, a racial disparity risk that is 10 years longer than that in the general ESRD population. Accounting for area-level median household income and transplantation significantly attenuated the disparity in mortality of African American versus non-African American patients with LN-caused ESRD.

Effects of Traumatic Amputation on ß-Trace Protein and ß2-Microglobulin Concentrations in Male Soldiers.

BACKGROUND: Serum creatinine (SCr) levels are decreased following traumatic amputation, leading to the overestimation of glomerular filtration rate (GFR). ß-Trace protein (BTP) and ß2-microglobulin (B2M) strongly correlate with measured GFR and have not been studied following amputation. We hypothesized that BTP and B2M would be unaffected by traumatic amputation. METHODS: We used the Department of Defense Serum Repository to compare pre- and post-traumatic amputation serum BTP and B2M levels in 33 male soldiers, via the N Latex BTP and B2M nephelometric assays (Siemens Diagnostics, Tarrytown, N.Y., USA). Osterkamp estimation using DEXA scan measurements was used to establish percent estimated body weight loss (%EBWL). Results were analyzed for small (3-5.9% EBWL), medium (6-13.5%), and large (>13.5%) amputation subgroups; and for a control group matched 1:1 to the 12 large amputation subjects. Paired Student's t test was used for comparisons. RESULTS: Mean serum BTP levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. BTP appeared to decrease following large %EBWL amputation (p = 0.05). Mean serum B2M levels were unchanged in controls, all amputees, and the small and medium amputation subgroups. B2M appeared to increase following large %EBWL amputation (p = 0.05). CONCLUSIONS: BTP and B2M levels are less affected than SCr by amputation, and should be considered for future study of GFR estimation. BTP and B2M changes following large %EBWL amputation require validation and may offer insight into non-GFR BTP and B2M determinants as well as increased cardiovascular disease and mortality following amputation.

Impact of Poverty and Health Care Insurance on Arteriovenous Fistula Use among Incident Hemodialysis Patients.

BACKGROUND: The impact of socioeconomic factors on arteriovenous fistula (AVF) creation in hemodialysis (HD) patients is not well understood. We assessed the association of area and individual-level indicators of poverty and health care insurance on AVF use among incident end-stage renal disease (ESRD) patients initiated on HD. METHODS: In this retrospective cohort study using the United States Renal Data System database, we identified 669,206 patients initiated on maintenance HD from January 1, 2007 through December 31, 2012. We assessed the Medicare-Medicaid dual-eligibility status as an indicator of individual-level poverty and ZIP code-level median household income (MHI) data obtained from the 2010 United States Census. We conducted logistic regression of AVF use at start of dialysis as the outcome variable. RESULTS: The proportions of dual-eligible and non-dual-eligible patients who initiated HD with an AVF were 12.53 and 16.17%, respectively (p<0.001). Dual eligibility was associated with significantly lower likelihood of AVF use upon initiation of HD (adjusted odds ratio (aOR) 0.91; 95% CI 0.90-0.93). Patients in the lowest area-level MHI quintile had an aOR of 0.97 (95% CI 0.95-0.99) compared to those in higher quintile levels. However, dual eligibility and area-level MHI were not significant in patients with Veterans Affairs (VA) coverage. CONCLUSIONS: Individual- and area-level measures of poverty were independently associated with a lower likelihood of AVF use at the start of HD, the only exception being patients with VA health care benefits. Efforts to improve incident AVF use may require focusing on pre-ESRD care to be successful.

A mixed methods study of how clinician 'super users' influence others during the implementation of electronic health records.

BACKGROUND: Despite the potential for electronic health records (EHRs) to improve patient safety and quality of care, the intended benefits of EHRs are not always realized because of implementation-related challenges. Enlisting clinician super users to provide frontline support to employees has been recommended to foster EHR implementation success. In some instances, their enlistment has been associated with implementation success; in other cases, it has not. Little is known about why some super users are more effective than others. The purpose of this study was to identify super users' mechanisms of influence and examine their effects on EHR implementation outcomes. METHODS: We conducted a longitudinal (October 2012 - June 2013), comparative case study of super users' behaviors on two medical units of a large, academic hospital implementing a new EHR system. We assessed super users' behaviors by observing 29 clinicians and conducting 24 in-depth interviews. The implementation outcome, clinicians' information systems (IS) proficiency, was assessed using longitudinal survey data collected from 43 clinicians before and after the EHR start-date. We used multivariable linear regression to estimate the relationship between clinicians' IS proficiency and the clinical unit in which they worked. RESULTS: Super users on both units employed behaviors that supported and hindered implementation. Four super user behaviors differed between the two units: proactivity, depth of explanation, framing, and information-sharing. The unit in which super users were more proactive, provided more comprehensive explanations for their actions, used positive framing, and shared information more freely experienced significantly greater improvement in clinicians' IS proficiency (p =0.03). Use of the four behaviors varied as a function of super users' role engagement, which was influenced by how the two units' managers selected super users and shaped the implementation climate. CONCLUSIONS: Super users' behaviors in implementing EHRs vary substantively and can have important influence on implementation success.