Implementation of an Academic-to-Community Hospital Intensive Care Unit Quality Improvement Program. Qualitative Analysis of Multilevel Facilitators and Barriers.

Rationale: Implementation of evidence-based best practices is influenced by a variety of contextual factors. It is vital to characterize such factors to maintain high-quality care. Patients in the intensive care unit (ICU) are critically ill and require complex, interdisciplinary, evidence-based care to enable high-quality outcomes. Objectives: To identify facilitators and barriers to implementation of an academic-to-community hospital ICU interprofessional quality improvement program, "ICU Innovations." Methods: ICU Innovations is a multimodal quality improvement program implemented between 2014 and 2017 in six community ICUs in rural settings serving underserved patients in South Carolina. ICU Innovations includes quarterly on-site seminars and extensive behind the scenes facilitation to catalyze the implementation of evidence-based best practices. We use qualitative analysis to identify contextual factors related to program implementation processes. Guided by an implementation science framework, the Exploration, Adoption/Preparation, Implementation, Sustainment framework, we conducted semistructured key informant interviews with clinician champions at six community ICUs and six parallel interviews with ICU Innovations' leadership. We developed a qualitative coding template based on the framework and identified contextual factors associated with implementation. Standard data on hospital and ICU structure and processes of care were also collected. Results: Outer and inner factors interconnected dynamically to influence implementation of ICU Innovations. Collaborative engagement between the program developers and partner sites (outer context factor) and site program champion leadership and staff readiness for change (inner context factors) were key influences of implementation. Conclusions: This research focused on rural hospital ICUs with limited or nonexistent intensivist leadership. Although enthusiasm for the ICU Innovations program was initially high, implementation was challenging because of multiple contextual factors. Critical steps for implementation of evidence-based practice in rural hospitals include optimizing engagement with external collaborators, maximizing the role of a committed site champion, and conducting thorough site assessments to ensure staff and organizational readiness for change. Identifying barriers and facilitators to program implementation is an on-going process to tailor and improve program initiatives.

Colorectal Cancer Screening in US Seniors Ages 76-84 Years.

The US Preventive Services Task Force recommends patient-physician discussions about the appropriateness of colorectal cancer (CRC) screening among adults ages 76-84 years who have never been screened. In this study, we used data from the 2010 National Health Interview Survey to examine patterns of CRC screening and provider recommendation among seniors ages 76-84 years, and made some comparisons to younger adults. Nationally-representative samples of 1379 adults ages 76-84 years and 8797 adults ages 50-75 years responded to questions about CRC screening status, receipt of provider recommendation, and discussion of test options; 22.7% (95% CI 20.1-25.3) of seniors ages 76-84 had never been tested for CRC and therefore were not up-to-date with guidelines; 3.9% (95% CI 2.0-7.6) of these individuals reported a recent provider recommendation for screening. In multivariate analyses, the likelihood of never having been tested was significantly greater for seniors of other/multiple race or Hispanic ethnicity; with high school or less education; without private health insurance coverage; who had ≤ 1 doctor visit in the past year; without recent screening for breast, cervical, or prostate cancer; with no or unknown CRC family history; or with ≤ 1 chronic disease. Among the minority of respondents ages 50-75 and 76-84 reporting a provider recommendation, 73.2% indicated that the provider recommended particular tests, which was overwhelmingly colonoscopy (≥ 89 %). Nearly one-quarter of adults 76-84 have never been screened for CRC, and rates of provider recommendation in this group are very low. Greater attention to informed CRC screening discussions with screening-eligible seniors is needed.

Follow-up to abnormal cancer screening tests: considering the multilevel context of care.

The call for multilevel interventions to improve the quality of follow-up to abnormal cancer screening has been out for a decade, but published work emphasizes individual approaches, and conceptualizations differ regarding the definition of levels. To investigate the scope and methods being undertaken in this focused area of follow-up to abnormal tests (breast, colon, cervical), we reviewed recent literature and grants (2007-2012) funded by the National Cancer Institute. A structured search yielded 16 grants with varying definitions of "follow-up" (e.g., completion of recommended tests, time to diagnosis); most included minority racial/ethnic group participants. Ten grants concentrated on measurement/intervention development and 13 piloted or tested interventions (categories not mutually exclusive). All studies considered patient-level factors and effects. Although some directed interventions at provider levels, few measured group characteristics and effects of interventions on the providers or levels other than the patient. Multilevel interventions are being proposed, but clarity about endpoints, definition of levels, and measures is needed. The differences in the conceptualization of levels and factors that affect practice need empirical exploration, and we need to measure their salient characteristics to advance our understanding of how context affects cancer care delivery in a changing practice and policy environment.

Breast and colorectal cancer screening: U.S. primary care physicians' reports of barriers.

BACKGROUND: Primary care physicians (PCPs) play a key role in performing and referring patients for cancer screening. Understanding barriers to test use is critical to developing strategies that promote adherence to clinical guidelines, but current literature does not distinguish the extent to which barriers may be similar or unique across screening modalities. PURPOSE: To describe PCPs' self-reported perceptions of barriers to screening for breast and colorectal cancer (CRC) and compare the top three barriers associated with these screening modalities. METHODS: Cross-sectional data analyzed in 2011 from a nationally representative survey of 2478 PCPs in the U.S. in 2006-2007. RESULTS: PCPs reported greater barriers for CRC screening than for mammography. Lack of patient follow-through to complete recommended screening and the inability to pay for tests were the main barriers perceived by PCPs for both types of screening. Another major barrier cited was that patients do not perceive CRC as a threat. This was a lesser concern for the well-diffused message about the need for mammography. CONCLUSIONS: This is the first national study to provide a comparison of physician-perceived barriers to breast and CRC screening. Study results suggest that efforts to improve use of cancer screening, and CRC screening in particular, will require interventions at physician, practice, and health-system levels.

Physicians' colorectal cancer screening discussion and recommendation patterns.

BACKGROUND: Primary care physician (PCP) actions are pivotal to colorectal cancer (CRC) screening performance, and guidelines recommend discussion with patients about test options and potential benefits and harms. This article profiles patterns of discussion about and recommendations for screening and explores potential associations with multilevel factors (patient, clinician, practice, and environment). METHODS: In 2009, we analyzed data from 1,266 physicians responding to the 2006-2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (absolute response rate=69.3%; cooperation rate=75.0%). Descriptive statistics examined physicians' reports of discussion and recommendations. Multivariate analyses assessed the associations of these practices with multilevel factors. RESULTS: Although few respondents reported discussion of all options, 46% usually discuss more than one option; the vast majority of these respondents discuss fecal occult blood testing (FOBT) and colonoscopy (49%) or FOBT, sigmoidoscopy, and colonoscopy (32%). Of physicians who discuss more than one option, a majority reported usually recommending one or more test options, most commonly colonoscopy alone (43%) and FOBT and colonoscopy (43%). Several personal characteristics (specialty), perceived patient characteristics (prefer physician to decide), practice characteristics (geographic location), and community barriers (specialist availability) were independently associated with discussion and/or recommendation patterns. CONCLUSIONS: PCPs do not discuss the full menu of test options, but many report selecting one or two options for discussion and recommendation. To ensure that patients' perspectives and concerns are elicited and considered, patient decision-making approaches should be considered. IMPACT: Attention to informed decision making in CRC screening will be important for enhancing patient-centered quality care.

Lifestyle behaviours and weight among hospital-based nurses.

AIMS: The purpose of this study was to (i) describe the weight, weight-related perceptions and lifestyle behaviours of hospital-based nurses, and (ii) explore the relationship of demographic, health, weight and job characteristics with lifestyle behaviours. BACKGROUND: The obesity epidemic is widely documented. Worksite initiatives have been advocated. Nurses represent an important part of the hospital workforce and serve as role models when caring for patients. METHODS: A sample of 194 nurses from six hospitals participated in anthropometric measurements and self-administered surveys. RESULTS: The majority of nurses were overweight and obese, and some were not actively involved in weight management behaviours. Self-reported health, diet and physical activity behaviours were low, although variable by gender, age and shift. Reports of co-worker norms supported low levels of healthy behaviours. CONCLUSIONS: Findings reinforce the need to address the hospital environment and culture as well as individual behaviours for obesity control. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse managers have an opportunity to consider interventions that promote a climate favourable to improved health habits by facilitating and supporting healthy lifestyle choices (nutrition and physical activity) and environmental changes. Such efforts have the potential to increase productivity and morale and decrease work-related disabilities and improve quality of life.

Surveying physicians: do components of the "Total Design Approach" to optimizing survey response rates apply to physicians?

BACKGROUND: Surveys serve essential roles in clinical epidemiology and health services research. However, physician surveys frequently encounter problems achieving adequate response rates. Research on enhancing response rates to surveys of the general public has led to the development of Dillman's "Total Design Approach" to the design and conduct of surveys. The impact of this approach on response rates among physicians is uncertain. OBJECTIVE: To determine the extent to which the components of the total design approach have been found to be effective in physician surveys. DESIGN: A systematic review. RESULTS: The effectiveness of prepaid financial incentives, special contacts, and personalization to enhance response rates in surveys of physicians have been confirmed by the existing research. There is suggestive evidence supporting the use of first class stamps on return envelopes and multiple contacts. The optimum amount for incentives and the number of contacts necessary have not been established. Details of questionnaire design and their impact on response rates have received almost no attention from researchers. Few studies have assessed the usefulness of combinations of components of the total design approach. CONCLUSIONS: Despite the number of surveys conducted among physicians, their cost, the level of interest in their findings, and in spite of inadequate response rates, there have been few randomized trials conducted on important aspects of enhancing response in this population. Until this gap has been filled, researchers conducting surveys of physicians should consider including all components of the total design approach whenever feasible.