Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia.

OBJECTIVES: We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP). METHODS: We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year. RESULTS: We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC. CONCLUSION: Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Effect of Elementary School-Based Health Centers in Georgia on the Use of Preventive Services.

INTRODUCTION: This study measures effects on the receipt of preventive care among children enrolled in Georgia's Medicaid or Children's Health Insurance Program associated with the implementation of new elementary school-based health centers. The study sites differed by geographic environment and predominant race/ethnicity (rural white, non-Hispanic; black, small city; and suburban Hispanic). METHODS: A quasi-experimental treatment/control cohort study used Medicaid/Children's Health Insurance Program claims/enrollment data for children in school years before implementation (2011-2012 and 2012-2013) versus after implementation (2013-2014 to 2016-2017) of school-based health centers to estimate effects on preventive care among children with (treatment) and without (control) access to a school-based health center. Data analysis was performed in 2017-2019. There were 1,531 unique children in the treatment group with an average of 4.18 school years observed and 1,737 in the control group with 4.32 school years observed. A total of 1,243 Medicaid/Children's Health Insurance Program-insured children in the treatment group used their school-based health centers. RESULTS: Significant increases in well-child visits (5.9 percentage points, p<0.01) and influenza vaccination (6.9 percentage points, p<0.01) were found for children with versus without a new school-based health center. This represents a 15% increase from the pre-implementation percentage (38.8%) with a well-child visit and a 25% increase in influenza vaccinations. Increases were found only in the 2 school-based health centers with predominantly minority students. The 18.7 percentage point (p<0.01) increase in diet/counseling among obese/overweight Hispanic children represented a doubling from a 15.3% baseline. CONCLUSIONS: Implementation of elementary school-based health centers increased the receipt of key preventive care among young, publicly insured children in urban areas of Georgia, with potential reductions in racial and ethnic disparities.

Implementation of Florida Long Term Care Emergency Preparedness Portal Web Site, 2015-2017.

We built an online emergency preparedness Web site for Florida nursing homes after an earlier study revealed gaps in information and a lack of available preparedness resources for long-term care providers. The Long Term Care Emergency Preparedness Portal ( www.ltcprepare.org ) was launched in January 2015. We assessed its use and sought suggestions for improvement. Findings indicate that long-term care providers in Florida regularly use the Web site, and they welcome the opportunity to further leverage technology to aid their disaster planning.

Georgia's Medicaid Family Planning Waiver: Working Together with Title X to Enhance Access to and Use of Contraceptive and Preventive Health Services.

PURPOSE: We sought to assess the impact of Georgia's family planning demonstration waiver upon access to and use of contraceptive and preventive health services within Title X and Medicaid. PROCEDURES: Georgia Title X and Medicaid data for January 2009 through December 2013 (before and after the waiver), restricting Title X data to women targeted by the waiver (18-44 years, incomes from 25% and 50% through 200% of the federal poverty level [FPL]) was assembled by quarter and marginal effects of the changes before and after waiver implementation were derived using multivariate regression models. FINDINGS: After implementation, there was a significant increase in the probability of Title X clients in the waiver-targeted age and income ranges who had Medicaid versus no insurance and who exited the encounter with higher effectiveness contraceptive methods, including long-acting reversible contraceptives (LARCs), and with cervical cytology and sexually transmitted infection testing. In the Medicaid data from 2009 to 2013, there was an increase in the mean number of encounters per enrollee (2.19 vs. 2.42) and in LARC users; however, the percentage of all Georgia women living under 200% of the FPL with a family planning encounter in Title X and Medicaid decreased from 19% to 15%. CONCLUSIONS: Our findings suggest that implementation of the Georgia family planning demonstration waiver contributed to the increased use of higher effectiveness contraceptive methods, including LARCs, within the Medicaid and Title X programs as well as the increased use of preventive screenings among Title X clients. However, when the full population of low-income Georgia women targeted by the waiver was considered, a greater percentage was not served over the demonstration period.

Quality improvement training: experiences of frontline staff.

PURPOSE: Healthcare organizations have employed numerous strategies to promote quality improvement (QI) initiatives, yet little is known about their effectiveness. In 2008, staff in one organization developed an in-house QI training program designed for frontline managers and staff and this article aims to report employee perspectives. DESIGN/METHODOLOGY/APPROACH: Qualitative interviews were conducted with 22 course participants to examine satisfaction, self-assessed change in proficiency and ability to successfully engage with QI initiatives. Sampling bias may have occurred as the participants volunteered for the study and they may not represent all course participants. Recall bias is also possible since most interviews took place one year after the course was completed to assess long-term impact. Respondents were asked to self-rate their pre- and post-course knowledge and skill, which may not represent what was actually learned. FINDINGS: Informants reported that the course expanded their QI knowledge and skills, and that supervisor support for the course was essential for success. Additionally, the course QI project provided participants with an opportunity to translate theory into practice, which has the potential to influence patient outcomes. PRACTICAL IMPLICATIONS: Several lessons for future QI training can be gleaned from this evaluation, including respondent opinions that it is challenging to offer one program when participants have different QI knowledge levels before the course begins, that "booster sessions" or refresher classes after the course ends would be helpful and that supervisor support was critical to successful QI-initiative implementation. ORIGINALITY/VALUE: This study conducts in-depth interviews with QI course participants to elicit staff feedback on program structure and effectiveness. These findings can be used by QI educators to disseminate more effective training programs.

Designing insurance to promote use of childhood obesity prevention services.

Childhood obesity is a recognized public health crisis. This paper reviews the lessons learned from a voluntary initiative to expand insurance coverage for childhood obesity prevention and treatment services in the United States. In-depth telephone interviews were conducted with key informants from 16 participating health plans and employers in 2010-11. Key informants reported difficulty ensuring that both providers and families were aware of the available services. Participating health plans and employers are beginning new tactics including removing enrollment requirements, piloting enhanced outreach to selected physician practices, and educating providers on effective care coordination and use of obesity-specific billing codes through professional organizations. The voluntary initiative successfully increased private health insurance coverage for obesity services, but the interviews described variability in implementation with both best practices and barriers identified. Increasing utilization of obesity-related health services in the long term will require both family- and provider-focused interventions in partnership with improved health insurance coverage.

Caregiver measures for seizure control, efficacy, and tolerability of antiepileptic drugs for childhood epilepsy: results of a preference survey.

We sought to identify and quantify caregiver-defined characteristics of efficacy related to the perceived success of antiepileptic drug (AED) use. A 22-question survey was designed using physician input, focus groups, and clinical trial endpoints. Responses were pooled and analyzed with regard to seizure type and treatment, categorized as controlled (exposure to 1 AED), adjunctive (exposure to 2 AEDs), or refractory (exposure to ≥3 AEDs). Two hundred ninety-five surveys were completed: 109 (37%) controlled, 84 (28%) adjunctive, and 102 (35%) refractory. Seizure freedom and median seizure reduction >90% maintained for >1 year were reported as the most important indicators of medication efficacy by the majority of respondents. These measures were the same regardless of seizure type or treatment category. Our results demonstrate that current trial design may be inadequate to address the expectations of patients. Incorporating patient-defined AED efficacy measures may improve satisfaction and informed decision making regarding epilepsy treatment.

A two-pronged quality improvement training program for leaders and frontline staff.

BACKGROUND: A unique two-pronged QI training program was developed at Emory Healthcare (Atlanta), which encompasses five hospitals and a multispecialty physician practice. One two-day program, Leadership for Healthcare Improvement, is offered to leadership, and a four-month program, Practical Methods for Healthcare Improvement, is offered to frontline staff and middle managers. KNOWLEDGE ASSESSMENT: Participants in the leadership program completed self-assessments of QI competencies and pre- and postcourse QI knowledge tests. Semistructured interviews with selected participants in the practical methods program were performed to assess QI project sustainability and short-term outcomes. RESULTS: More than 600 employees completed one of the training programs in 2008 and 2009. Leadership course participants significantly improved knowledge in all content areas, and self-assessments revealed high comfort levels with QI principles following the training. All practical methods participants were able to initiate and implement QI projects. Participants described significant challenges with team functionality, but a majority of the QI projects made progress toward achieving their aim statement goals. A review of completed projects shows that a significant number were sustained up to one year after program completion. Quality leaders continue to modify the program based on learner feedback and institutional goals. CONCLUSIONS: This initiative shows the feasibility of implementing a broad-based in-house QI training program for multidisciplinary staff across an integrated health system. Initial assessment shows knowledge improvements and successful QI project implementations, with many projects active up to one year following the courses.

Effectiveness of a patient and practice-level colorectal cancer screening intervention in health plan members: the CHOICE trial.

BACKGROUND: Colorectal cancer (CRC) screening reduces CRC incidence and mortality but is underused. Effective interventions to increase screening that can be implemented broadly are needed. METHODS: A controlled trial was conducted to evaluate a patient-level and practice-level intervention to increase the use of recommended CRC screening tests among health plan members. The patient-level intervention was a patient decision aid and included stage-targeted brochures that were mailed to health plan members. Intervention practices received academic detailing to prepare practices to facilitate CRC testing once patients were activated by the decision aid. We used patient surveys and claims data to assess CRC test completion. RESULTS: Among 443 active participants, 75.8% were ages 52 to 59 years, 80.9% were white, 62.1% were women, and 46.4% had college degrees or greater education. Among 380 active participants with known screening status at 12 months based on survey results, 39% in the intervention group reported receiving CRC screening compared with 32.2% in the usual care group (unadjusted odds ratio [OR], 1.34; 95% confidence interval; [CI], 0.88-2.05; P = .17). After adjusting for baseline differences and accounting for clustering, the effect was somewhat larger (OR, 1.64; 95% CI, 0.98-2.73; P = .06). Claims analysis produced similar effects for active participants. The intervention was more effective in those who had incomes >$50,000 (OR, 2.16; 95% CI, 1.07-4.35) than in those who had lower incomes (OR, 1.25; 95% CI, 0.53-2.94; P = .03 for interaction). CONCLUSIONS: Interventions combining a patient-directed decision aid and practice-directed academic detailing had a modest but statistically nonsignificant effect on CRC screening rates among active participants.

Patient activation is associated with healthy behaviors and ease in managing diabetes in an indigent population.

PURPOSE: The purpose of this study is to assess the validity of the patient activation construct as measured by the Patient Activation Measure (PAM) survey by correlating PAM scores with diabetes self-management behaviors, attitudes, and knowledge in a predominantly minority and uninsured population. METHODS: A convenience sample of patients presenting to an urban public hospital diabetes clinic was surveyed and contacted by phone 6 months later. The survey included questions about activation, health behaviors, and health care utilization. RESULTS: A total of 287 patients agreed to participate. Most were African American, female, and uninsured. Most respondents (62.2%) scored in the highest category of activation according to the PAM. Activated patients were more likely to perform feet checks, receive eye examinations, and exercise regularly. Activation was consistently associated with less reported difficulty in managing diabetes care but not with A1C knowledge. PAM scores at the initial interview were highly correlated with scores at 6-month follow-up. Activation level did not predict differences in health care utilization during the 6 months following the survey. CONCLUSIONS: Higher scores on the PAM were associated with higher rates of self-care behaviors and ease in managing diabetes; however, the indigent urban population reported higher activation scores than found in previous studies. The relationship between activation and outcomes needs to be explored further prior to expanding use of this measure in this patient population.

Is the availability of hospital IT applications associated with a hospital's risk adjusted incidence rate for patient safety indicators: results from 66 Georgia hospitals.

This study examines the associations between the availability of IT applications in a hospital and that hospital's risk adjusted incidence rate per 1,000 hospitalizations for Agency for Healthcare Research and Quality's (AHRQ) 15 Patient Safety Indicators (PSIs). The study population consists of a convenience sample of 66 community hospitals in Georgia that completed a Hospital IT survey by December 2003 and provided data to Georgia Hospital Discharge Data Set during 2004. AHRQ's PSI software was used to estimate risk adjusted incidence rates. Differences in means, Pearson correlation coefficients, and multivariate regression analysis were used to determine if the availability of IT applications were associated with better PSI outcomes. This study finds very little statistically significant correlation between the availability of IT applications and risk adjusted PSI incident rate per 1,000

Adopting National Quality Forum medication safe practices: Progress and barriers to hospital implementation.

BACKGROUND: To reduce medical errors, the National Quality Forum (NQF) developed consensus-based guidelines of 30 safe practices recommended for all hospitals OBJECTIVE: To determine the hospital characteristics and barriers that influence the rates of adoption of these practices. DESIGN: Retrospective review of annual self-assessment surveys from 2003 to 2004. Medication and culture of safety questions from the survey were mapped to the relevant NQF safe practices. SETTING: One hundred and forty-eight acute care hospitals. MEASUREMENTS: Bivariate analysis was used to examine variation in adoption rates by hospital demographic characteristics. RESULTS: Most hospitals had adopted 7 of the 9 medication-related practices. Lower adoption rates were seen for resource-intensive safe practices such as consultant pharmacists (52.0%) or CPOE (2.7%). The safety culture questions showed broad diffusion of nonpunitive error reporting (83.7%) but more limited adoption of proactive processes to detect and prevent errors (44.9%). There were no differences by urban versus rural setting and few differences by hospital size. Safe practices that affected hospital-based physicians such as ensuring that new prescribers had access to all currently prescribed medications and minimizing distractions during order writing were difficult for many hospitals. Lower adoption rates were also seen for processes requiring direct physician participation such as eliminating verbal orders and using standardized abbreviations. CONCLUSIONS: Adoption of NQF-recommended safe practices appeared related to resource constraints and hospital culture. Promoting physician involvement as clinical leaders and team builders, moving from reactive reporting systems to proactive processes that prevent errors, and developing more robust monitoring systems will facilitate further adoption of safe practices.

Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population?

BACKGROUND: Studies indicate that adverse drug events (ADEs) are common and costly. It appears that the elderly are at greater risk of ADEs because they use more medications, have less specific presentations, and have more chronic conditions than younger populations. OBJECTIVE: The goal of this study was to determine if the number of physicians prescribing medications to an elderly patient was associated with that patient's likelihood of reporting an ADE. METHODS: This cohort study was a secondary analysis of data collected from a previous survey of Medicare managed care enrollees aged > or =65 years at the time of enrollment. A telephone survey of residents in the Philadelphia, Pennsylvania, area was conducted. Data included self-reported information on the number of prescribing physicians, chronic conditions, medications, ADEs, and general health status. RESULTS: A total of 405 patients (mean [SD] age, 74 [5.1] years) were included in the study. Enrollees had a mean (SD) of 2.9 (1.3) prescribing physicians, and 98 (24%) patients reported having experienced an ADE in the previous 6 months. The mean (SD) number of self-reported chronic medical conditions and number of prescription medications was 4.7 (2.4) and 4.0 (2.8), respectively. In a multivariable logistic regression model, each additional provider prescribing medications increased the odds of reporting an ADE by 29% (odds ratio [OR], 1.3; 95% CI, 1.0-1.6). The number of chronic health conditions was also associated with ADEs. Having 4 or 5 self-reported chronic conditions doubled a person's odds of experiencing an ADE (OR, 2.1; 95% CI, 1.0-4.1) and having > or =6 conditions tripled the likelihood of experiencing an ADE (OR, 3.4; 95% CI, 1.6-6.9). The number of prescription medications or taking a potentially contraindicated medication was not significantly associated with self-reported ADEs. CONCLUSIONS: In this study population, the number of prescribing physicians was an independent risk factor for patients self-reporting an ADE. More research is needed to confirm and explain this finding. One possibility is poor communication between multiple providers. Physicians should work to ensure more effective coordination of care between providers and communicate information about all medications prescribed to their patients with their colleagues.

Implementation and evaluation of a nursing home fall management program.

OBJECTIVES: To evaluate the feasibility and effectiveness of a falls management program (FMP) for nursing homes (NHs). DESIGN: A quality improvement project with data collection throughout FMP implementation. SETTING: NHs in Georgia owned and operated by a single nonprofit organization. PARTICIPANTS: All residents of participating NHs. INTERVENTION: A convenience sample of 19 NHs implemented the FMP. The FMP is a multifaceted quality improvement and culture change intervention. Key components included organizational leadership buy-in and support, a designated facility-based falls coordinator and interdisciplinary team, intensive education and training, and ongoing consultation and oversight by advanced practice nurses with expertise in falls management. MEASUREMENTS: Process-of-care documentation using a detailed 24-item audit tool and fall and physical restraint use rates derived from quality improvement software currently used in all Georgia NHs (MyInnerView). RESULTS: Care process documentation related to the assessment and management of fall risk improved significantly during implementation of the FMP. Restraint use decreased substantially during the project period, from 7.9% to 4.4% in the intervention NHs (a relative reduction of 44%), and decreased in the nonintervention NHs from 7.0% to 4.9% (a relative reduction of 30%). Fall rates remained stable in the intervention NHs (17.3 falls/100 residents per month at start and 16.4 falls/100 residents per month at end), whereas fall rates increased 26% in the NHs not implementing the FMP (from 15.0 falls/100 residents/per month to 18.9 falls/100 residents per month). CONCLUSION: Implementation was associated with significantly improved care process documentation and a stable fall rate during a period of substantial reduction in the use of physical restraints. In contrast, fall rates increased in NHs owned by the same organization that did not implement the FMP. The FMP may be a helpful tool for NHs to manage fall risk while attempting to reduce physical restraint use in response to the Centers for Medicare and Medicaid Services quality initiatives.

Urban-rural differences in the availability of hospital information technology applications: a survey of Georgia hospitals.

CONTEXT: Information technology (IT) has been identified as a potential tool for improving the safety of health care delivery. PURPOSE: To determine if there are significant differences between urban and rural community hospitals in the availability of selected IT functional applications and technological devices. METHODS: A mailed survey of community hospitals in Georgia assessing the current availability of IT applications (54.6% response rate). FINDINGS: Georgia hospitals reported having 63.6% of 56 possible functional applications computerized but only 52.9% of 41 technological devices. Compared to rural hospitals, urban hospitals had significantly more functional applications computerized (38.0 vs 31.8, P = .031) and technological devices available (23.9 vs 18.2, P = .016). Urban hospitals had significantly (P < .05) more IT applications available in 4 areas: emergency room services (7 of 10), surgical/operating room (8 of 12), laboratory (7 of 12), and radiology (5 of 11). Overall, the availability of IT applications was bimodal in rural hospitals: over 40% of rural hospitals had adopted over 70% of all applications, while approximately 26% of rural hospitals had adopted less than 30%. CONCLUSIONS: Some of the observed urban/rural differences in availability of IT applications may be due to differences in the scope of services provided by rural hospitals, in particular laboratories, radiology departments, emergency rooms, and surgery/operating rooms. Nevertheless, the bimodal distribution of IT applications adopted in rural hospitals raises concerns about the ability of selected rural hospitals to take advantage of regional data-sharing initiatives and maintain quality of patient care in the future.

Can an algorithm for appropriate prescribing predict adverse drug events?

OBJECTIVE: To evaluate whether a medication-appropriateness algorithm applied to pharmacy claims data can identify ambulatory patients at risk for experiencing adverse drug events (ADEs) from those medications. STUDY DESIGN: Cohort study. METHODS: We surveyed a random sample of 211 community-dwelling Medicare managed care enrollees over age 65 years who were identified by pharmacy claims as taking a potentially contraindicated medication (exposed enrollees) and a random sample of 195 enrollees who were identified as not taking such a medication (unexposed enrollees). The primary outcome of interest was the prevalence of self-reported events in previous 6 months. RESULTS: Ninety-nine (24.4% of total sample) respondents reported a total of 134 ADEs during the previous 6 months. Exposed enrollees had a significantly higher number of chronic conditions and were taking more prescription and nonprescription medications. However, the higher rate of self-reported ADEs among exposed enrollees was not statistically significant from that of unexposed enrollees (prevalence odds ratio = 1.42; 95% confidence interval [CI] = 0.90, 2.25). Only 1.5% (2/134) of the self-reported ADEs were attributed to a medication from the potentially contraindicated list. Instead, most ADEs were attributed to medications that are commonly used in older patients, including cardiovascular agents (21.6%), anti-inflammatory agents (12.2%), and cholesterol-lowering agents (7.9%). CONCLUSIONS: A medication-appropriateness algorithm using pharmacy claims data was not able to identify a subgroup of enrollees at higher risk of experiencing an ADE from those medications. The vast majority of ADEs were attributable to commonly prescribed medications.