Lean Implementation for Graduating Optimally Controlled Stable Type 2 Diabetics from Endocrine Specialty Clinic Back to Primary Care.

INTRODUCTION: Endocrine specialty clinics (SCs) are occupied by a high percentage of stable follow-up patients, limiting access to new patients with greater needs. AIM: Feasibility project to improve access to diabetes SC by reducing the number of stable optimally controlled follow-up type 2 diabetic patients. SETTING: M Health Fairview (MHFV), a hybrid network of University of Minnesota academic and Fairview Health community hospitals and clinics with affiliated providers. PROGRAM DESCRIPTION: A team-based lean methodology quality improvement graduation program including medical assistants, nurses, physicians, and a compact with primary care (PC) was used to identify within the Endocrine clinic population the graduation-eligible optimally controlled stable type 2 diabetic patients, acclimate them to the graduation concept, engage in shared decision-making, and transition them back to PC with a warm hand-off and graduation certificate. PROGRAM EVALUATION: Seventeen percent (58/341) of eligible patients with optimally controlled diabetes graduated by 6 months, ranging between 0 and 83% per week. DISCUSSION: The innovation and feasibility of opening SC access through the use of a team-based graduation program to transfer stable diabetes patients back to their home clinic was demonstrated. This innovation has the potential to support health system triage of new patients to limited access specialty care.

Process evaluation of a systemic intervention to identify and support partner violence survivors in a multi-specialty health system.

BACKGROUND: Intimate partner violence (IPV) is highly prevalent in the United States and impacts the physical and mental health and social well-being of those who experience it. Healthcare settings are important intervention points for IPV screening and referral, yet there is a wide range of implementation of IPV protocols in healthcare settings in the U.S., and the evidence of the usefulness of IPV screening is mixed. This process evaluation investigates the facilitators and barriers to implementing Coordinated Care for IPV Survivors through the M Health Community Network ("M Health Network"), an intervention that aimed to standardize IPV screening and referral in a multi-specialty clinic and surgery center (CSC). Two validated IPV screens were introduced and mandated to be done by rooming staff at least once every 3 months with all clinic patients regardless of gender; the Humiliation Afraid Rape Kick (HARK) for presence of IPV and the shortened Danger Assessment (DA-5) for lethality of IPV. Upon a positive screen, the patient was offered immediate informational resources and, if willing, was referred to a social worker for care coordination with a community organization. METHODS: Semi-structured, individual and group process interviews with clinic managers and clinic staff at 8 CSC clinics (N = 24) were undertaken at 3,12, and 27 months after intervention start. Semi-structured interviews were undertaken with the research team (N = 3) post-implementation. A Consolidated Framework for Implementation Research (CFIR) codebook was used to code data in two rounds. After each round, thick description was used to write detailed and contextual descriptions of each code. Facilitators and barriers to implementation were identified during the second round of thick description. RESULTS: Facilitators to implementation were clinic staff support, dedication, and flexibility and research team engagement. Barriers were lack of prioritization, loss of intervention champions, lack of knowledge about intervention protocol and resources, staff and patient discomfort discussing IPV, and operational issues with screen technology. CONCLUSIONS: The IPV protocol was implemented, but faced common barriers. CFIR is a complex, but comprehensive, tool to guide process evaluation for IPV screening and referral interventions in health systems in the U.S.

Linking partner violence survivors to supportive services: impact of the M Health Community Network project on healthcare utilization.

BACKGROUND: Intimate partner violence (IPV) is associated with adverse health effects and increased healthcare utilization. Systems-level interventions have been shown to be effective in identifying and referring survivors but little is known about how these strategies impact future utilization. The objective of this study is to examine the impact of a systems-level response on healthcare utilization among patients screening positive for IPV from November 2016 to February 2019 in a large multi-specialty outpatient health system in the Midwest. METHODS: Using electronic health record (EHR) data, we identified patients who screened positive for IPV (N = 756) and categorized their response as accepted printed material (N = 116), accepted direct referrals (N = 85), declined both (N = 271), or missing (N = 255). We used negative binomial models to model post-period utilization as a function of decision group, pre-period utilization, and clinical and demographic factors. RESULTS: After controlling for demographic characteristics and baseline utilization, the printed materials and direct referral groups had higher utilization rates than those who declined printed materials and direct referral during the post-period for every type of service. However, these differences were only statistically significant for outpatient, behavioral health, and social work services. Specifically, the visit rate for patients receiving printed materials was two times higher (rate ratio: 2.18; 95% CI: 1.21, 3.94) for behavioral health services and three times higher (rate ratio: 3.33; 95% CI: 1.3, 8.52) for social work services compared to those who refused printed material and direct referral. For those opting for a direct referral, the visit rate was two times higher for outpatient services (rate ratio: 1.97; 95% CI: 1.13, 3.42) compared to those who refused. CONCLUSIONS: Patients receiving printed materials or direct referrals had more social work and behavioral health visits, highlighting an important outcome of the protocol. However, higher utilization rates among outpatient services and a trend toward higher utilization of other services, including the emergency department, suggest greater health service utilization is not diminished by the systems level response-at least not within a two-year time frame.

Weight change after antiretroviral therapy and mortality.

BACKGROUND: Weight gain after antiretroviral therapy (ART) initiation is common, but its implication for mortality is unknown. We evaluated weight change in the first year after ART initiation and its association with subsequent mortality. METHODS: Human immunodeficiency virus-infected patients from the Veterans Aging Cohort Study (VACS) who initiated ART between 2000 and 2008, with weight recorded at baseline and 1 year later, were followed another 5 years for mortality. Baseline body mass index (BMI) was classified as underweight (<18.5 kg/m(2)), normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). We used multivariable Cox models to assess mortality risk with adjustment for disease severity using the VACS Index. RESULTS: The sample consisted of 4184 men and 127 women with a mean age of 47.9 ± 10.0 years. After 1 year of ART, median weight change was 5.9 pounds (2.7 kg) (interquartile range, -2.9 to 17.0 pounds, -1.3 to 7.7 kg). Weight gain after ART initiation was associated with lower mortality among underweight and normal-weight patients. A minimum threshold of 10- to 19.9-pound (4.5 to 9.0 kg) weight gain was beneficial for normal-weight patients (hazard ratio, 0.56; 95% confidence interval, .41-.78), but there was no clear benefit to weight gain for overweight/obese patients. Baseline weight, CD4 cell count status, and hemoglobin level were strongly associated with weight gain. Risk for weight gain was higher among those with greater disease severity, regardless of weight at initiation. CONCLUSIONS: The survival benefits of weight gain after ART initiation are dependent on starting BMI. Weight gain after ART is associated with lower mortality for those who are not initially overweight.

Gender Distribution of Authors of Evaluation Letters for Promotion at One Medical School.

PURPOSE: Women remain underrepresented in key leadership positions and advanced ranks in academic medicine. This study examines the numbers of men and women letter writers for promotion candidates during a 5-year period across departments, tracks, ranks, and candidate gender. METHOD: A descriptive study characterized the gender of evaluation letter writers for candidates for promotion to associate or full professor at the University of Minnesota Medical School between 2015 and 2020. Letter writer and candidate gender were characterized by self-identified pronouns in the faculty biography or dossier. Letter writer gender was described by candidate department, promotion track, rank, terminal degree, and gender. RESULTS: Among 299 candidates for promotion, 172 (58%) were men and 127 (42%) were women; dossiers included 3,995 evaluation letters. Across all years, men wrote more letters than women (external letters, range, 69% in 2019-2020 to 75% in 2015-2016; internal letters, range, 67% in 2018-2019 to 77% in 2015-2016). Candidates in the family medicine and pediatrics departments had the highest percentages of letters written by women (44% and 40%, respectively). No differences were found in the number of women letter writers by candidate promotion track; however, differences were found by candidate rank (associate professor, 30%; full professor, 23%) and terminal degree (MD/DO, 25%; PhD, 33%; MD-PhD, 20%). Regardless of candidate gender, most evaluation letters were written by men. Women candidates had 15% to 20% more letters authored by women than men candidates (34%-40% vs 18%-23%). CONCLUSIONS: The gender pattern of letter writers may reflect implicit biases regarding gender and perceived leadership status, expertise, and success. Adopting policies that promote or require gender diversity among letter writers for promotion candidates may provide an opportunity to encourage faculty to seek diverse networks and recognize the achievements of women faculty.

Health Care Providers' Readiness to Identify and Respond to Intimate Partner Violence.

Screening rates for intimate partner violence (IPV) among most health care providers are low; yet, positive interactions with providers can benefit people who experience IPV, with respect to increased safety, support, and self-efficacy. Missing is a broad assessment and comparison of knowledge, attitudes, and behavior across the range of providers who are likely to be involved in a response to IPV disclosure. The purpose of our study was to assess health care providers' IPV preparation, knowledge, opinions, and practices and examine differences across three types of health care providers (medical providers, nursing staff, and social/behavioral health providers). We used an anonymous online survey to gather self-reported information on preparation, knowledge, opinions, and practices around IPV. A random sample of 402 providers was drawn from 13 clinics in a large multispecialty outpatient practice setting. The respondents (N = 204) consisted of medical providers (n = 70), nursing staff (n = 107), and social/behavioral health providers (n = 27). Data analyses consisted of univariate, bivariate, and multivariate analyses. Social/behavioral health providers reported more preparation, knowledge, victim understanding, and less job-related constraints, yet they reported lower screening rates than medical providers and nursing staff. Overall, no provider group seemed well-equipped to work with patients who disclose IPV. Our findings identify unmet needs within our health system to better train health care providers and restructure care models to support IPV identification and response. A focus on interprofessional training and care collaboration would bolster competency and reduce constraints felt by the health care workforce.

Longitudinal trends in screening males and females for intimate partner violence as part of a systemic multi-specialty health system intervention.

OBJECTIVE: To assess intimate partner violence screening for males and females in a health system that underwent a systemic intervention to improve survivor identification and response. Electronic health record data from 13 clinics were accessed for February of 2017, 2018, and 2019 to calculate screening rates and positive screening rates for intimate partner violence by clinic and sex-race groups (n = 11,693 non-Hispanic White females; n = 4318 Other females; n = 9184 non-Hispanic White males; n = 3441 Other males). Linear mixed effects models were used to examine whether screening rates differed significantly over time and by sex-race group. RESULTS: Screening rates were 31% for the first 2 years and 16% for 2019. Screening rates varied greatly by clinic. Dermatology, psychiatry, and otolaryngology clinics had average or above screening rates all 3 years. Differences in screening rates across sex-race groups were minimal. Average positive screen rates were 1.3%, 0.4%, and 2.6% in 2017, 2018, and 2019, respectively, with psychiatry having the highest positive screen rate. Positive screen rates were highest for non-Hispanic White females (3.5%). Universal screening in this health system was not yielding survivors comparable to existing estimates among clinic-based populations. Other identification approaches require testing to effectively identify survivors within the health sector.

Intimate Partner Violence Screening and Referral Practices in an Outpatient Care Setting.

Health care providers who screen for intimate partner violence (IPV) and counsel patients can reduce victimization and positively impact women's health and well-being; yet only 2% to 50% of medical professionals report routinely screening female patients. The purpose of this study was to identify current practices, policies, barriers, and opportunities for a coordinated and routinized response to IPV in an outpatient academic primary care clinic. Data were collected through interviews and the Physician Readiness to Manage Intimate Partner Violence questionnaire. Data on IPV screening practices over a 5-month period were also available through the electronic health record. Study participants expressed that there was no uniform method of documenting screening results and great variability in the patient populations and circumstances that prompted screening. Over two thirds of the survey respondents reported either a lack of IPV protocol or a lack of knowledge about one if it existed. Providers and staff who participated believed it was within their scope of work to screen for IPV and recognized IPV as a serious health threat; however, they cited an absence of patient education resources, a lack of staff training and awareness, and no established IPV referral network as barriers to screening for IPV. The results of the pilot are in line with existing research highlighting a general lack of screening, variability in process, and the absence of systems-level policies and protocols and linkages to community resources. Pilot findings have been used to initiate a project which encompasses routinized screening, documentation, and care coordination between providers and community organizations to improve patient well-being.