A landscape assessment of CTSA evaluators and their work in the CTSA consortium, 2021 survey findings.

This article presents a landscape assessment of the findings from the 2021 Clinical and Translational Science Award (CTSA) Evaluators Survey. This survey was the most recent iteration of a well established, national, peer-led systematic snapshot of the CTSA evaluators, their skillsets, listed evaluation resources, preferred methods, and identified best practices. Three questions guided our study: who are the CTSA evaluators, what competencies do they share and how is their work used within hubs. We describe our survey process (logistics of development, deployment, and differences in historical context with prior instruments); and present its main findings. We provide specific recommendations for evaluation practice in two main categories (National vs Group-level) including, among others, the need for a national, strategic plan for evaluation as well as enhanced mentoring and training of the next generation of evaluators. Although based on the challenges and opportunities currently within the CTSA Consortium, takeaways from this study constitute important lessons with potential for application in other large evaluation consortia. To our knowledge, this is the first time 2021 survey findings are disseminated widely, to increase transparency of the CTSA evaluators' work and to motivate conversations within hub and beyond, as to how best to leverage existent evaluative capacity.

Self-Assessment of Research Skills and Barriers to Research Careers among Pulmonary and Critical Care Fellows.

BACKGROUND: Recruitment and retention of Pulmonary and Critical Care Medicine (PCCM) trainees into academic research positions remain difficult. Factors influencing graduates, like salary and personal circumstances, remain unchangeable. However, some program-level factors, like research skill acquisition and mentorship, may be modifiable to encourage matriculation into academic research positions. OBJECTIVE: We aim to identify proficiency in research-specific skills in PCCM trainees and barriers to careers as research-focused academic faculty. METHODS: We surveyed PCCM fellows in a nationwide cross-sectional analysis including demographics, research intent, research skills self-assessment, and academic career barriers. The Association of Pulmonary and Critical Care Medicine Program Directors approved and disseminated the survey. Data were collected and stored using the REDCap database. Descriptive statistics were used to assess survey items. RESULTS: 612 fellows received the primary survey with 112 completing the survey for a response rate of 18.3%. A majority were male (56.2%) and training at university-based medical centers (89.2%). Early fellowship trainees (first-/second-year fellows) comprised 66.9% of respondents with 33.1% being late fellowship trainees (third-/fourth-year fellows). Most early trainees (63.2%) indicated they intended to incorporate research into their careers. A chi-square testing of independence was performed to examine the relationship between training level and perceived proficiency. Significant relationships in perceived proficiency were identified between early and late fellowship trainees with an absolute difference of 25.3% (manuscript writing), 18.7% (grant writing), 21.6% (study design), and 19.5% (quantitative/qualitative methodology). The most prevalent barriers were unfamiliarity with grant writing (59.5%) and research funding uncertainty (56.8%). CONCLUSION: With an ongoing need for academic research faculty, this study identifies self-perceived gaps in research skills including grant writing, data analytics, and study conception and design. These skills map to fellow-identified barriers to careers in academics. Mentorship and innovative curriculum focusing on the development of key research skills may enhance academic research faculty recruitment.

Understanding how health systems facilitate primary care redesign.

OBJECTIVE: To understand how health systems are facilitating primary care redesign (PCR), examine the PCR initiatives taking place within systems, and identify barriers to this work. STUDY SETTING: A purposive sample of 24 health systems in 4 states. STUDY DESIGN: Data were systematically reviewed to identify how system leaders define and implement initiatives to redesign primary care delivery and identify challenges. Researchers applied codes which were based on the theoretical PCR literature and created new codes to capture emerging themes. Investigators analyzed coded data then produced and applied a thematic analysis to examine how health systems facilitate PCR. DATA COLLECTION: Semi-structured telephone interviews with 162 system executives and physician organization leaders from 24 systems. PRINCIPAL FINDINGS: Leaders at all 24 health systems described initiatives to redesign the delivery of primary care, but many were in the early stages. Respondents described the use of centralized health system resources to facilitate PCR initiatives, such as regionalized care coordinators, and integrated electronic health records. Team-based care, population management, and care coordination were the most commonly described initiatives to transform primary care delivery. Respondents most often cited improving efficiency and enhancing clinician job satisfaction, as motivating factors for team-based care. Changes in payment and risk assumption as well as community needs were commonly cited motivators for population health management and care coordination. Return on investment and the slower than anticipated rate in moving from fee-for-service to value-based payment were noted by multiple respondents as challenges health systems face in redesigning primary care. CONCLUSIONS: Given their expanding role in health care and the potential to leverage resources, health systems are promising entities to promote the advancement of PCR. Systems demonstrate interest and engagement in this work but face significant challenges in getting to scale until payment models are in alignment with these efforts.

Communicating and disseminating research findings to study participants: Formative assessment of participant and researcher expectations and preferences.

INTRODUCTION: Translating research findings into practice requires understanding how to meet communication and dissemination needs and preferences of intended audiences including past research participants (PSPs) who want, but seldom receive, information on research findings during or after participating in research studies. Most researchers want to let others, including PSP, know about their findings but lack knowledge about how to effectively communicate findings to a lay audience. METHODS: We designed a two-phase, mixed methods pilot study to understand experiences, expectations, concerns, preferences, and capacities of researchers and PSP in two age groups (adolescents/young adults (AYA) or older adults) and to test communication prototypes for sharing, receiving, and using information on research study findings. PRINCIPAL RESULTS: PSP and researchers agreed that sharing study findings should happen and that doing so could improve participant recruitment and enrollment, use of research findings to improve health and health-care delivery, and build community support for research. Some differences and similarities in communication preferences and message format were identified between PSP groups, reinforcing the best practice of customizing communication channel and messaging. Researchers wanted specific training and/or time and resources to help them prepare messages in formats to meet PSP needs and preferences but were unaware of resources to help them do so. CONCLUSIONS: Our findings offer insight into how to engage both PSP and researchers in the design and use of strategies to share research findings and highlight the need to develop services and support for researchers as they aim to bridge this translational barrier.

Teleneurology Network to Improve Access to Neurologists for Patients in Rural Areas: A Real-World Experience.

Background: The need for neurologists has been steadily increasing over the past few years. The implementation of teleneurology networks could serve as a potential solution to this need. Methods: A retrospective review of the Medical University of South Carolina (MUSC) Teleneurology records for all consults performed between August 2014 and July 2018 was conducted. Collected data included number of consults, baseline characteristics, final diagnosis, and number of providers and hospitals over the study period. Results: A total of 4,542 Teleneurology consults were performed during the study period. The most common diagnosis was cerebrovascular disease, followed by seizure disorders. The number of consults per month increased throughout the study period from three in August 2014 to 257 in July 2018. The number of community hospitals covered has increased from 3 hospitals in August 2014 to 14 hospitals throughout the state of South Carolina in July 2018. Conclusion: Over 4 years, the MUSC teleneurology program has evolved into a robust partnership with 14 partner hospitals, and is now delivering more than 250 expert neurology consultations monthly to patients throughout the state of South Carolina.

Development and Evolution of a Statewide Outpatient Consultation Service: Leveraging Telemedicine to Improve Access to Specialty Care.

Despite a robust health care system in the United States, many Americans experience health care disparities as a result of poor access to medical care. Academic medicine plays an important role in addressing health care disparities by providing primary and specialty care for the poor and uninsured. In South Carolina, 43 of its 46 counties are designated as fully or partially Medically Underserved Areas (MUAs), defined as areas with a shortage of medical providers, high infant mortality, and either high elderly population or high poverty rates. To address these health care disparities, an academic medical center in South Carolina created a hub-and-spoke specialty care model using telemedicine in partnership with primary care providers across community settings. Initial private foundation grant funding enabled the development and dissemination of technology to provide remote teleconsultations by physicians at the academic medical center (hub) to patients in their primary care offices (spoke). This model, now supported by recurring state funding and professional billing, provides much-needed services, including psychiatry, nutrition counseling, and various surgical and medical subspecialties, to rural and underserved populations in the state. This manuscript provides a narrative review of the development of this statewide telemedicine service, with an emphasis on identification of stakeholders, technology issues, barriers to implementation, and future directions.

Utilization of Outpatient Telehealth Services in Parity and Nonparity States 2010-2015.

Background and Introduction: Telehealth is a promising approach to improving healthcare access and quality. While coverage for telehealthcare has expanded, reimbursement remains one of the biggest barriers to provider adoption. Thirty-four states and the District of Columbia have enacted parity legislation requiring private insurance companies to provide some level of reimbursement coverage for telehealth services. MATERIALS AND METHODS: The purpose of this article is to describe the trends in telehealth utilization from 2010 to 2015 for privately insured patients. Using a nationally representative sample of patient data from the 2010-2015 Truven® MarketScan Commercial Claims dataset, we examine the change over time in the utilization of outpatient telehealth visits between states enacting parity legislation and those who do not. RESULTS: We found the states with parity laws saw significant increases in the number of outpatient telehealth visits. Controlling for year, the odds of receiving a telehealth visit in a parity state were 29.8% greater than in a nonparity state (p < 0.0001). DISCUSSION AND CONCLUSION: Telehealth remains a small percentage of all outpatient private health insurance claims. Enactment of telehealth parity legislation is related to significant increases in the utilization of telehealth outpatient services. Further expansion of private telehealth insurance coverage may encourage increased utilization of telehealth services. However, telehealth reimbursement coverage varies greatly across parity states. Future examination of the impact of individual state-level policy options on telehealth utilization is warranted.

Stroke Administrative Severity Index: using administrative data for 30-day poststroke outcomes prediction.

AIM: Current stroke severity scales cannot be used for archival data. We develop and validate a measure of stroke severity at hospital discharge (Stroke Administrative Severity Index [SASI]) for use in billing data. METHODS: We used the NIH Stroke Scale (NIHSS) as the theoretical framework and identified 285 relevant International Classification of Diseases, 9th Revision diagnosis and procedure codes, grouping them into 23 indicator variables using cluster analysis. A 60% sample of stroke patients in Medicare data were used for modeling risk of 30-day postdischarge mortality or discharge to hospice, with validation performed on the remaining 40% and on data with NIHSS scores. RESULTS: Model fit was good (p > 0.05) and concordance was strong (C-statistic = 0.76-0.83). The SASI predicted NIHSS at discharge (C = 0.83). CONCLUSION: The SASI model and score provide important tools to control for stroke severity at time of hospital discharge. It can be used as a risk-adjustment variable in administrative data analyses to measure postdischarge outcomes.

Inhaled Corticosteroid Claims and Outpatient Visits After Hospitalization for Asthma Among Commercially Insured Children.

OBJECTIVE: To determine rates of inhaled corticosteroid (ICS) claims and outpatient follow-up after asthma hospitalization among commercially insured children. METHODS: We conducted a retrospective cohort analysis of children hospitalized for asthma using 2013 national Truven MarketScan data. Covariates included age, sex, region, length of stay, and having an ICS claim within 35 days before hospitalization. Outcome variables were a claim for any ICS-containing medication and outpatient visit within 30 days after discharge. Multivariable analysis used logistic regression. RESULTS: A total of 5471 children aged 2 to 17 were included; 61% were boys, and mean age was 6.8 years. Forty-one percent had a claim for an ICS and 76% had an outpatient visit within 30 days after hospital discharge. In multivariable analysis, children who had an ICS claim within 35 days before the hospitalization were more likely to have an ICS claim within 30 days after discharge (relative risk [RR] 1.3, 95% confidence interval [CI] 1.2-1.5). The strongest predictor of an ICS claim within 30 days after discharge was attendance at an outpatient appointment (RR 1.4, 95% CI 1.3-1.6). Children aged 2 to 6 were more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.1-1.2). Children with an ICS claim before admission were also more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.004-1.1). CONCLUSIONS: In this national sample of commercially insured children with asthma, rates of ICS claims after hospitalization are low despite high rates of outpatient visits. Both inpatient and outpatient physicians must play a role in increasing ICS adherence in this high-risk population of children with asthma.

Improving care delivery at the community level: an examination of the AF4Q legacy.

OBJECTIVE: Aligning Forces for Quality (AF4Q) was the Robert Wood Johnson Foundation's nearly 10-year, multicomponent initiative to create meaningful and sustainable change in 16 communities. Our purpose was to describe the likely legacy of the care delivery component of AF4Q among participating communities and the factors that influenced the legacy. METHODS: We used a multiple-case study approach. Our analysis relied on 3 key documents for each community, based on key informant interviews conducted between 2006 and 2015: (1) a summary of the community's care delivery activities under AF4Q, (2) a summary of the community's experience in the AF4Q program, and (3) a summary of the characteristics of each community and the multi-stakeholder alliance that led local efforts under AF4Q. We used a team-based consensual approach to analysis. RESULTS: We identified 3 types of legacies: (1) in 3 communities, there appear to be sustained infrastructures or wide-reaching activities attributable to AF4Q; (2) in 5 communities, AF4Q participation was used to advance preexisting activities; and (3) in 8 communities, the care delivery legacy is likely to be limited, because the local alliance focused on performance measurement instead of care delivery or the care delivery activities had limited reach and sustainability. Community contextual factors (eg, availability of other grant support) and alliance characteristics (eg, areas of expertise) greatly influenced the AF4Q care delivery legacy. CONCLUSION: AF4Q appears to have created meaningful and sustained change in care delivery in half of the participating communities. Among the other communities, the considerable financial support and technical assistance provided by RWJF was not enough to overcome some of the contextual barriers that often hamper quality-improvement efforts.

Using multi-stakeholder alliances to accelerate the adoption of health information technology by physician practices.

BACKGROUND: Multi-stakeholder alliances - groups of payers, purchasers, providers, and consumers that work together to address local health goals - are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities. METHODS: Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 - March 2009 and January 2012-November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients' online access to their medical records. RESULTS: Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients' online access to medical records between AF4Q and non-AF4Q communities. CONCLUSION: By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients' online access to medical records. IMPLICATIONS: Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Investigating a Multistakeholder Alliance Approach to Reducing Hospital Readmissions.

There is growing appreciation that significant improvements in healthcare quality cannot be achieved by organizations working in isolation. To that end, the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative provides multistakeholder alliances-groups of payers, purchasers, providers, and consumers that work together-with funding and technical assistance to improve healthcare community wide. Reducing readmissions was one of the several AF4Q goals. Alliances crafted their own interventions, tailored to address the communities' unique needs, and took advantage of local resources. Our objective was to determine whether readmission rates declined more in AF4Q communities than in non-AF4Q communities by year 7 of the 10-year initiative. We conducted a quasiexperimental study using zip code-level demographics and 30-day readmission rates for all medical and surgical discharges using Medicare claims data for 2008 through 2012. This interim analysis found that AF4Q was not associated with significant reductions in medical or surgical readmissions, suggesting that AF4Q's multistakeholder approach was no more effective at reducing readmissions than other national efforts, such as the Hospital Reduction Program under the Affordable Care Act.

Patient-Centered Medical Home Adoption: Results From Aligning Forces For Quality.

To improve health care quality within communities, increasing numbers of multistakeholder alliances-groups of payers, purchasers, providers, and consumers-have been created. We used data from two rounds (conducted in July 2007-March 2009 and January 2012-November 2013) of a large nationally representative survey of small and medium-size physician practices. We examined whether the adoption of patient-centered medical home processes spread more rapidly in fourteen Robert Wood Johnson Foundation Aligning Forces for Quality communities, where multistakeholder health care alliances promoted their use, than in other communities. We found no difference in the overall growth of adoption of the processes between the two types of communities. However, improvement on a care coordination subindex was 7.17 percentage points higher in Aligning Forces for Quality communities than in others. Despite the enthusiasm for quality improvement led by multistakeholder alliances, such alliances may not be a panacea for spreading patient-centered medical home processes across a community.

Building the scaffold to improve health care quality in Western New York.

Many health policy leaders are promoting the community as a place to try out new ideas for improving the quality of health care. Alliances with multiple stakeholders are moving forward with communitywide efforts to improve the quality of care without the benefit of an established evidence base or guiding framework. This article presents a profile of one community's attempt to facilitate and coordinate quality improvement in its geographic area. The P(2) Collaborative of Western New York is one of sixteen sites supported by the Robert Wood Johnson Foundation's national Aligning Forces for Quality initiative. The strategy and vision of the collaborative has evolved as it has tried to capitalize on opportunities and overcome barriers in its work. The article concludes with a discussion of eight tasks that community alliances may consider undertaking when establishing an infrastructure for improving the quality of health care, such as convening area stakeholders to develop a strategy and finding ways to monitor health outcomes at the local level on an ongoing basis.