A framework and process for community-engaged, mixed-methods cancer needs assessments.

PURPOSE: Community health needs assessments are required for most state and local public health agencies and non-profit hospitals. Typically based on community health improvement planning models, these assessments encompass overall community health and multiple diseases to inform program planning. National Cancer Institute (NCI)-designated Cancer Centers and community-based cancer-focused programs share the goal of reducing cancer burden in the catchment areas they serve. However, to date, no published models exist to guide cancer-specific needs assessments for a determined geographic area that can inform both public health and research initiatives. The purpose of this article is to outline a cancer needs assessment (CNA) framework and community-engaged, mixed-methods process, along with a case study of how we applied it in Kentucky. METHODS: We convened a steering committee of key organizational partners to provide input throughout the process. We developed a conceptual framework of multi-level determinants affecting cancer-related outcomes. We incorporated both quantitative and qualitative data gathered through a variety of means, including a novel application of group concept mapping to guide definition of priorities. RESULTS: The resulting CNA has helped guide strategic planning and priorities for Kentucky's Cancer Action Plan, Markey Cancer Center, state agencies, and community-based organizations. CONCLUSION: This framework and process can be used collaboratively by cancer center Community Outreach and Engagement offices, public health agencies, oncology programs, and community partners to plan impactful cancer control programs and research in their catchment areas. Universities can also use them to inform the planning of community engagement and health equity research efforts.

Measurement of provider fidelity to immunization guidelines: a mixed-methods study on the feasibility of documenting patient refusals of the human papillomavirus vaccine.

BACKGROUND: Assessment and feedback is a common implementation strategy to improve healthcare provider fidelity to clinical guidelines. For immunization guidelines, fidelity is often measured with doses administered during eligible visits. Adding a patient refusal measure captures provider fidelity more completely (i.e., all instances of a provider recommending a vaccine, resulting in vaccination or refusal) and enables providers to track patient vaccine hesitancy patterns. However, many electronic health record (EHR) systems have no structured field to document multiple instances of refusals for specific vaccines, and existing billing codes for refusal are not vaccine specific. This study assessed the feasibility of a novel method for refusal documentation used in a study focused on human papillomavirus (HPV) vaccine. METHODS: An observational, descriptive-comparative, mixed-methods study design was used to conduct secondary data analysis from an implementation-effectiveness trial. The parent trial compared coach-based versus web-based practice facilitation, including assessment and feedback, to increase HPV vaccination in 21 community-based private pediatric practices. Providers were instructed to document initial HPV vaccine refusals in the EHR's immunization forms and subsequent refusals using dummy procedure codes, for use in assessment and feedback reports. This analysis examined adoption and maintenance of the refusal documentation method during eligible well visits, identified barriers and facilitators to documentation and described demographic patterns in patient refusals. RESULTS: Seven practices adopted the refusal documentation method. Among adopter practices, documented refusals started at 2.4% of eligible well visits at baseline, increased to 14.2% at the start of implementation, peaked at 24.0%, then declined to 18.8%. Barriers to refusal documentation included low prioritization, workflow integration and complication of the billing process. Facilitators included high motivation, documentation instructions and coach support. Among adopter practices, odds of refusing HPV vaccine were 25% higher for patients aged 15-17 years versus 11-12 years, and 18% lower for males versus females. CONCLUSIONS: We demonstrated the value of patient refusal documentation for measuring HPV vaccination guideline fidelity and ways that it can be improved in future research. Creation of vaccine-specific refusal billing codes or EHR adaptations to enable documenting multiple instances of specific vaccine refusals would facilitate consistent refusal documentation. Trial Registration NCT03399396 Registered in ClinicalTrials.gov on 1/16/2018.

Patient and Provider Perspectives on Pediatric Telemedicine During the COVID-19 Pandemic.

The COVID-19 pandemic led to rapid expansion of telemedicine services. We surveyed parent/guardians from March 10 to June 29, 2020, in an academic and community pediatric practice, and community pediatric providers from June 5 to July 13, 2020, to better understand their perceptions of telemedicine and compare parent/guardian satisfaction between in-person and telemedicine encounters. Overall patient satisfaction scores were high in both settings and did not differ between in-person and telemedicine visits (community setting: 93.36 ± 12.87 in-person vs. 88.04 ± 22.04 telemedicine; academic setting: 92.25 ± 11.2 vs. 95.37 ± 8.21). Most providers (82.5%) would be willing to use telemedicine in a nonpandemic situation. Telemedicine should remain available for primary care pediatrics during and after resolution of the pandemic.

Social network analysis as an analytic tool for interaction patterns in primary care practices.

PURPOSE: Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices. METHODS: Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams. RESULTS: The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described. CONCLUSIONS: SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

How complexity science can inform a reflective process for improvement in primary care practices.

BACKGROUND: Quality improvement processes have sometimes met with limited success in small, independent primary care settings. The theoretical framework for these processes uses an implied understanding of organizations as predictable with potentially controllable components. However, most organizations are not accurately described using this framework. Complexity science provides a better fit for understanding small primary care practices. METHODS: The Multimethod Assessment Process (MAP)/Reflective Adaptive Process (RAP) is informed by complexity science. This process was developed in a series of studies designed to understand and improve primary care practice. A case example illustrates the application and impact of the MAP/RAP process. RESULTS: Guiding principles for a reflective change process include the following: an understanding of practices' vision and mission is useful in guiding change, learning and reflection helps organizations adapt to and plan change, tension and discomfort are essential and normal during change, and diverse perspectives foster adaptability and new insights for positive change. DISCUSSION: A reflective change process that treats organizations as complex adaptive systems may help practices make sustainable improvements.

Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict.

PURPOSE: Electronic medical record (EMR) systems offer substantial opportunities to organize and manage clinical data in ways that can potentially improve preventive health care, the management of chronic illness, and the financial health of primary care practices. The functionality of EMRs as implemented, however, can vary substantially from that envisaged by their designers and even from those who purchase the programs. The purpose of this study was to explore how unique aspects of a family medicine office culture affect the initial implementation of an EMR. METHODS: As part of a larger study, we conducted a qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR. We collected data using participant observation, in-depth interviews, and key informant interviews. After the initial data collection, we shared our observations with practice members and returned 1 year later to collect additional data. RESULTS: Dysfunctional communication patterns, the distribution of formal and informal decision-making power, and internal conflicts limited the effective implementation and use of the EMR. The implementation and use of the EMR made tracking and monitoring of preventive health and chronic illness unwieldy and offered little or no improvement when compared with paper charts. CONCLUSIONS: Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an office practice and without methods for bringing to the surface and addressing conflicts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs.

Assessing diversity and quality in primary care through the multimethod assessment process (MAP).

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.