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1.
J Natl Med Assoc ; 111(6): 665-673, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31668360

RESUMO

BACKGROUND: Physician diversity is linked to improved quality of care of diverse patient populations. The transition from medical school to residency is an opportunity to improve and increase workforce diversity in all specialties. However, there is limited published literature on the factors contributing to the ranking of residency programs on women and underrepresented minorities (URMs). OBJECTIVE: To characterize factors medical students used to rank residency programs and describe any differences based on race/ethnicity or gender. METHODS: A mixed-methods study consisting of a web-based survey and semi-structured interviews with National Resident Matching Program (NRMP) participating graduates over a two-year period. The survey assessed demographics and a 6-point Likert scale rating of various factors used to rank residency programs. Unpaired student t-tests were used to compare means. A subset of students was interviewed and a modified grounded theory approach identified decision-making themes as well as the role of gender and URM status. RESULTS: Out of a total of 316 invitations sent, 148 completed the survey (46.8% response rate), of which 21% of respondents self-identified as URMs. The majority of respondents graduated in 2014 (53%), and were male (51%). Participants ranked program atmosphere, reputation, location, and proximity to family the highest. URM students ranked patient population (p < 0.01), revisit opportunities (p = 0.04), gender diversity (p < 0.01), and ethnic diversity (p < 0.01) significantly higher than non-URM students. Female students ranked patient population (p < 0.01) and gender diversity (p < 0.01) significantly higher than males. Qualitative findings revealed differences in perceptions by URMs and non-URMs of patient population, revisit opportunities, gender diversity, and ethnic diversity. CONCLUSIONS: While all students prioritized pragmatic factors, women and URM students assess and weigh additional factors related to culture, inclusion, and diversity more than others. By tailoring recruitment strategies to meet the expectations of women and URMs, residency programs can better meet goals in becoming more diverse and inclusive.

2.
Am J Prev Med ; 57(5): 652-658, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31564598

RESUMO

INTRODUCTION: Little is known about how provider bias can influence nonadherence labeling. Therefore, a retrospective cohort analysis was conducted to assess the risk of patients with Type 2 diabetes being labeled nonadherent by sociodemographic factors. METHODS: Patients with Type 2 diabetes were identified from 4 primary care sites of the University of Pennsylvania Health System. Demographics, HbA1c, and ICD-10 codes for Type 2 diabetes and nonadherence were extracted from the electronic health record and analyzed in October 2017. Log-binomial regression models were used to estimate patients' risk of nonadherence labeling by race, age, sex, BMI, and insurance payer while controlling for HbA1c as a proxy for medication use. RESULTS: This study included 3,768 adults aged 18-70 years with Type 2 diabetes who received care from 1 of 4 primary care sites at University of Pennsylvania from 2014 to 2017. An increased risk was found for black patients relative to white patients (RR=2.86, 95% CI=1.91, 4.27) and Medicaid (RR=1.8, 95% CI=1.45, 2.22) or Medicare (RR=1.69, 95% CI=1.36, 2.1) relative to private insurance to be labeled as nonadherent while adjusting for HbA1c. Though statistically insignificant, Hispanic patients also showed increased risk of nonadherence labeling. BMI, age, and sex showed no association. CONCLUSIONS: Black race and nonprivate insurance status were shown to be associated with increased risk of nonadherence labeling. The findings may indicate a concerning bias among providers in their perception of patient behavior by race and insurance.

4.
J Homosex ; : 1-13, 2019 Sep 17.
Artigo em Inglês | MEDLINE | ID: mdl-31526306

RESUMO

Recent recommendations to include patient sexual orientation (SO) and gender identity (GI) in the electronic health record (EHR) aim to improve clinical care and address health disparities among sexual and gender minority patients. Collection and documentation of GI may be complex due to multiple clinically relevant components. This study explored provider practices in collecting and documenting GI across multiple specialties. Qualitative interviews with 25 healthcare providers were transcribed verbatim, and thematic analysis and principles of grounded theory were used to analyze the data. Without a protocol and absent dedicated locations in the EHR for collecting and documenting patient GI, provider practices were inconsistent and highlighted challenges for communication across clinical staff. Providers noted that patients' disclosure of GI was typically unprompted, or was presumed through disclosure of gender affirming treatments. Findings indicate the need for provider training and appropriate EHR fields to support GI collection and documentation.

5.
Clin Exp Rheumatol ; 37 Suppl 121(6): 28-34, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31025933

RESUMO

OBJECTIVES: Behçet's syndrome (BS) is a multisystem variable-vessel vasculitis with significant life impact. The aim of this study was to explore the perspectives of patients with BS with different types of organ involvement. METHODS: Semi-structured qualitative interviews were conducted with 20 patients with BS with different types of organ involvement. Interviews were audio-recorded, transcribed, and translated into English. A Grounded Theory approach was employed in thematic analysis of translated interviews. RESULTS: Interviews with participants yielded four themes, including symptoms (skin problems, pain, vision problems, fatigue/sleep disturbances, and gastrointestinal/weight loss), impact on function (impact on speech and vision, mobility, energy for tasks, adaptations, and self-care), psychological impact (emotions and emotional management techniques), and social impact (ability to socialize generally and impact on familial relationships). CONCLUSIONS: Patients with BS identified several domains, including physical functioning, psychological state, and social identity that are significantly modulated by the symptoms of BS. Those are inter-related with physical symptoms, reflecting the multi-system character of BS, and impair patients' function impacting on psychological and social identities. This work advances an understanding of BS, and will be useful in developing patient-oriented outcome measures for use in studying BS.


Assuntos
Síndrome de Behçet , Transtornos do Sono-Vigília , Isolamento Social , Síndrome de Behçet/fisiopatologia , Síndrome de Behçet/psicologia , Emprego , Fadiga/etiologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Dor/etiologia , Transtornos do Sono-Vigília/etiologia , Baixa Visão/etiologia
6.
J Rheumatol ; 46(8): 928-934, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30824648

RESUMO

OBJECTIVE: The Patient Reported Outcome Measurement Information System (PROMIS) is a collection of item banks of self-reported health. This study assessed the feasibility and construct validity of using PROMIS instruments in vasculitis. METHODS: Data from a multicenter longitudinal cohort of subjects with systemic vasculitis were used. Instruments from 10 PROMIS item banks were selected with direct involvement of patients. Subjects completed PROMIS instruments using computer adaptive testing (CAT). The Medical Outcomes Study Short Form-36 (SF-36) was also administered. Cross-sectional construct validity was assessed by calculating correlations of PROMIS scores with SF-36 measures and physician and patient global scores for disease activity. Longitudinal construct validity was assessed by correlations of between-visit differences in PROMIS scores with differences in other measures. RESULTS: During the study period, 973 subjects came for 2306 study visits and the PROMIS collection was completed at 2276 (99%) of visits. The median time needed to complete each PROMIS instrument ranged from 40 to 55 s. PROMIS instruments correlated cross-sectionally with individual scales of the SF-36, most strongly with subscales of the SF-36 addressing the same domain as the PROMIS instrument. For example, PROMIS fatigue correlated with both the physical component score (PCS; r = -0.65) and with the mental component score (MCS; r = -0.54). PROMIS physical function correlated strongly with PCS (r = 0.81) but weakly with MCS (r = 0.29). Weaker correlations were observed longitudinally between change in PROMIS scores with change in PCS and MCS. CONCLUSION: Collection of data using CAT PROMIS instruments is feasible among patients with vasculitis and has some cross-sectional and longitudinal construct validity.

7.
J Rheumatol ; 46(10): 1415-1420, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30709951

RESUMO

OBJECTIVE: Aspects of antineutrophil cytoplasmic antibodies-associated vasculitis (AAV) prioritized by patients with AAV were described using the International Classification of Function, Disability, and Health (ICF). METHODS: Items identified during 14 individual interviews were incorporated into an ICF-based questionnaire administered to participants of 2 vasculitis patient symposia: 36 in the United Kingdom and 63 in the United States. RESULTS: Categories identified as at least "moderately relevant" by ≥ 5% of subjects included 44 body functions, 14 body structures, 35 activities and participation, 31 environmental factors, and 38 personal factors. CONCLUSION: Identified categories differ from those identified by the current Outcome Measures in Rheumatology (OMERACT) core set and those prioritized by vasculitis experts.

8.
Paediatr Anaesth ; 29(4): 345-352, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30710425

RESUMO

BACKGROUND: Previously published work established the need for a specialty-specific definition of professionalism in pediatric anesthesiology. That work established a composite definition consisting of 11 domains and their component "defining themes" for professionalism in pediatric anesthesiology. As a next step toward assessing generalizability of our single-center findings, we sought to gain input from a national sample of pediatric anesthesiologists. AIMS: The aim of this study was to establish the construct validity of our previously published multidimensional definition of professionalism in pediatric anesthesiology using a nationally representative sample of pediatric anesthesiologists. METHODS: A survey was distributed via snowball sampling to the leaders of every pediatric anesthesiology fellowship program and pediatric anesthesia department or clinical division in the United States. Survey items were designed to validate individual component themes in the working definition. For affirmed items, the respondent was asked to rate the importance of the item. Respondents were also invited to suggest novel themes to be included in the definition. RESULTS: A total of 216 pediatric anesthesiologists representing a variety of experience levels and practice settings responded to the survey. All 40 themes were strongly supported by the respondents, with the least supported theme receiving 71.6% approval. 92.8% of respondents indicated that the 11 domains previously identified formed a comprehensive list of domains for professionalism in pediatric anesthesiology. Four additional novel themes were suggested by respondents, including wellness/self-care/burnout prevention, political advocacy, justice within a practice organization, and respect for leadership/experienced partners. These are topics for future study. The survey responses also indicated a near-universal agreement that didactic lectures would be ineffective for teaching professionalism. CONCLUSION: This national survey of pediatric anesthesiologists serves to confirm the construct validity of our prior working definition of professionalism in pediatric anesthesiology, and has uncovered several opportunities for further study. This definition can be used for both curriculum and policy development within the specialty.


Assuntos
Anestesiologistas/normas , Anestesiologia/normas , Pediatria/normas , Profissionalismo/normas , Anestesiologistas/educação , Anestesiologia/educação , Humanos , Internato e Residência , Pediatria/educação , Profissionalismo/educação , Inquéritos e Questionários
9.
Fam Med ; 50(9): 698-701, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30307589

RESUMO

BACKGROUND AND OBJECTIVES: The national opioid crisis requires medical education to develop a proactive response centering on prevention and treatment. Primary care providers (PCPs)-many of whom are family medicine physicians-commonly treat patients on opiates, and write nearly 50% of opioid prescriptions. Despite linkages between PCP opioid prescribing patterns and the associated potential for overdose, little is known about how family medicine clerkship students are trained to prevent opioid overdose, including training on the use of naloxone. This study describes the presence of opioid overdose education at the national level and barriers to inclusion. It also discusses implementation strategies along with instructional methodology and learner evaluation. METHODS: Data were collected as part of a cross-sectional survey administered electronically by the Council of Academic Family Medicine Educational Research Alliance to 139 family medicine clerkship directors. RESULTS: A total of 99 clerkship directors (71.2% response rate) responded to the survey. A large majority (86.4%) agreed that it is important to offer opioid overdose prevention education in the clerkship, yet only 25.8% include this topic. Of these, only 50.0% address naloxone use. The most common barriers to including opioid overdose prevention education were prioritization of educational topics (82.1%) followed by lack of available faculty with sufficient experience/expertise (67.7%). CONCLUSIONS: Findings point to a disparity between perceived importance of opioid overdose prevention education and inclusion of this topic in family medicine clerkship-level medical education. Innovative use of online education and partnering with community resources may address barriers related to curricular prioritization while supporting interprofessional education principles.


Assuntos
Analgésicos Opioides/envenenamento , Estágio Clínico , Currículo , Overdose de Drogas/prevenção & controle , Medicina de Família e Comunidade/educação , Naloxona/uso terapêutico , Antagonistas de Entorpecentes/uso terapêutico , Estudos Transversais , Humanos
12.
Fam Med ; 50(8): 617-622, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30215822

RESUMO

BACKGROUND AND OBJECTIVES: Experiences of psychological trauma are common among primary care patient populations, and adversely affect patients' health and health care utilization. Trauma-informed care (TIC) is a framework for identifying and responding to patients' experiences of psychological trauma to avoid retraumatization. The purpose of this study was to evaluate the current state of TIC training in family medicine residency programs in the United States in order to identify opportunities for and barriers to TIC training. METHODS: Items addressing the four core domains of TIC were incorporated into the 2017 Council of Academy Family Medicine Educational Research Alliance (CERA) survey of program directors. The items assessed the presence, content, and sufficiency of TIC curriculum, as well as barriers to further integration of TIC training. RESULTS: Approximately 50% of programs responded to the survey. Of 263 respondents, 71 (27%) reported TIC training in their curriculum, but the majority devoted less than 5 hours annually to core content. The content most commonly addressed recognizing signs of trauma, most frequently using didactic formats. Overall, just over one-half of the programs reported that their curriculum met patients' TIC needs "somewhat" (48.5%) or "a great deal" (4.6%). Lack of a champion followed by lack of time were the most commonly cited barriers to integrating TIC training. CONCLUSIONS: Despite the acknowledged importance of effects of trauma in health care, this study identified insufficient exposure to training in the core TIC domains in family medicine residency programs, underscoring a need for greater integration of TIC training during residency.


Assuntos
Medicina de Família e Comunidade/educação , Internato e Residência/organização & administração , Trauma Psicológico , Currículo , Humanos , Trauma Psicológico/diagnóstico , Trauma Psicológico/terapia , Pesquisa , Inquéritos e Questionários , Estados Unidos
13.
Fam Med ; 50(5): 380-384, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29762799

RESUMO

BACKGROUND AND OBJECTIVES: Behavioral health integration (BHI) in primary care settings is critical to mental health care in the United States. Family medicine resident experience in BHI in family medicine residency (FMR) continuity clinics is essential preparation for practice. We surveyed FMR program directors to characterize the status of BHI in FMR training. METHODS: Using the Council of Academic Family Medicine Educational Research Alliance (CERA) 2017 survey, FMR program directors (n=478, 261 respondents, 54.6% response rate) were queried regarding the stage of BHI within the residency family medicine center (FMC), integration activities at the FMC, and the professions of the BH faculty. BHI was characterized by Substance Abuse and Mental Health Services Agency (SAMHSA) designations within FMRs, and chi-square or ANOVA with Tukey honest significant difference (HSD) post hoc testing was used to assess differences in reported BHI attributes. RESULTS: Program directors reported a high level of BHI in their FMCs (44.1% full integration, 33.7% colocated). Higher levels of BHI were associated with increased use of warm handoffs, same day consultation, shared health records, and the use of behavioral health (BH) professionals for both mental health and medical issues. Family physicians, psychiatrists, and psychologists were most likely to be training residents in BHI. CONCLUSIONS: Almost half of FMR programs have colocated BH care or fully integrated BH as defined by SAMHSA. Highly integrated FMRs use a diversity of behavioral professionals and activities. Residencies currently at the collaboration stage could increase BH provider types and BHI practices to better prepare residents for practice. Residencies with full BHI may consider focusing on supporting BHI-trained residents transitioning into practice, or disseminating the model in the general primary care community.


Assuntos
Medicina de Família e Comunidade/educação , Internato e Residência , Serviços de Saúde Mental/provisão & distribução , Psiquiatria/educação , Currículo , Prestação Integrada de Cuidados de Saúde , Educação de Pós-Graduação em Medicina , Feminino , Humanos , Masculino , Médicos , Inquéritos e Questionários , Estados Unidos
14.
Ann Rheum Dis ; 77(8): 1157-1164, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29695498

RESUMO

OBJECTIVES: To finalise and validate a disease-specific patient-reported outcome (PRO) measure: the ANCA-associated vasculitis patient-reported outcome (AAV-PRO) questionnaire. Using a 35-item candidate questionnaire developed following 50 qualitative interviews in the UK, USA and Canada, a longitudinal survey was conducted to determine the final scale structure and validate the AAV-PRO. METHODS: Participants were recruited via Vasculitis UK and the Vasculitis Patient-Powered Research Network. The 35-item candidate questionnaire was completed at baseline and 3 months; UK participants completed the EuroQol-5D-5L (EQ-5D-5L), while US participants completed a test-retest exercise, 3-5 days after baseline. Scale structure was defined using exploratory factor analysis (EFA) and Rasch analysis. Convergent and known groups validity, test-retest reliability and longitudinal construct validity were assessed. RESULTS: There were 626 participants with AAV; >25% reporting 'active disease'. EFA and Rasch analysis supported a 29-item profile measure comprising six domains: 'organ-specific symptoms', 'systemic symptoms', 'treatment side effects', 'social and emotional impact', 'concerns about the future' and 'physical function'. Mean domain scores were higher for participants with 'active disease' versus 'remission' (p<0.001). Construct validity was demonstrated by correlations between domain scores and the EQ-5D-5L (range r=-0.55 to 0.78), all p<0.0001. In participants reporting 'no change' (n=97) during the test-retest, intraclass correlation coefficient values were high (range 0.89-0.96) for each domain. CONCLUSIONS: The AAV-PRO, a new disease-specific PRO measure for AAV, has good face and construct validity, is reliable, feasible and discriminates among disease states.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/terapia , Medidas de Resultados Relatados pelo Paciente , Adulto , Idoso , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/psicologia , Canadá , Estudos de Viabilidade , Feminino , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Indução de Remissão , Reprodutibilidade dos Testes , Fatores Socioeconômicos , Inquéritos e Questionários , Reino Unido , Estados Unidos , Adulto Jovem
15.
Matern Child Health J ; 22(6): 883-892, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29429135

RESUMO

Objectives The aim of this paper is to explore the process and impact of co-locating evidence-based maternal and child service models to inform future implementation efforts. Methods As part of a state-wide evaluation of maternal and child home visiting programs, we conducted semi-structured interviews with administrators and home visitors from home visiting agencies across Pennsylvania. We collected 33 interviews from 4 co-located agencies. We used the Consolidated Framework for Implementation Research (CFIR) to describe the key elements mitigating implementation of multiple home visiting models. Results A primary advantage of co-location described by participants was the ability to increase the agency's base of eligible clients through the implementation of a model with different program eligibility (e.g. income, child age) than the existing agency offering. Model differences related to curriculum (e.g. content or intensity/meeting frequency) enabled programs to more selectively match clients to models. To recruit eligible clients, new models were able to build upon the existing service networks of the initial program. Co-location provided organizational opportunities for shared trainings, enabling administrative efficiencies and collaborative staff learning. Programs implemented strategies to build synergies with complementary model features, for instance using the additional program option to serve waitlisted clients and to transition services after one model is completed. Conclusions for Practice Considerable benefits are experienced when home visiting models co-locate. This research builds on literature encouraging collaboration among community agencies and provides insight on a specific facilitative approach. This implementation strategy informs policy across the social services spectrum and competitive funding contexts.


Assuntos
Saúde da Criança , Assistência à Saúde/organização & administração , Serviços de Assistência Domiciliar/organização & administração , Serviços de Saúde Materno-Infantil/organização & administração , Cuidado Pós-Natal , Criança , Assistência à Saúde/métodos , Medicina Baseada em Evidências , Feminino , Humanos , Entrevistas como Assunto , Pennsylvania , Gravidez , Pesquisa Qualitativa
16.
Artigo em Inglês | MEDLINE | ID: mdl-29379322

RESUMO

Objective: The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are multisystem diseases of the small blood vessels. Patients experience irreversible damage and psychological effects from AAV and its treatment. An international collaboration was created to investigate the impact of AAV on health-related quality of life (HRQoL), and develop a disease-specific patient-reported outcome measure to assess outcomes of importance to patients. Methods: Patients with AAV from the UK, USA, and Canada were interviewed to identify salient aspects of HRQoL affected by AAV. The study was overseen by a steering committee including four patient research partners. Purposive sampling of interviewees ensured representation of a range of disease manifestations and demographics. Inductive analysis was used to identify themes of importance to patients; these were further confirmed by a free-listing exercise in the US. Individual themes were recast into candidate items, which were scrutinized by patients, piloted through cognitive interviews and received a linguistic and translatability evaluation. Results: Fifty interviews, conducted to saturation, with patients from the UK, USA, and Canada, identified 55 individual themes of interest within seven broad domains: general health perceptions, impact on function, psychological perceptions, social perceptions, social contact, social role, and symptoms. Individual themes were constructed into >100 candidate questionnaire items, which were then reduced and refined to 35 candidate items. Conclusion: This is the largest international qualitative analysis of HRQoL in AAV to date, and the results have underpinned the development of 35 candidate items for a disease-specific, patient-reported outcome questionnaire.

17.
Rheumatol Int ; 38(4): 675-682, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29124398

RESUMO

Granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA) are multisystem diseases of small blood vessels, collectively known as the anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV). This study explores the patient's perspective on the use of glucocorticoids, which are still a mainstay of treatment in AAV. Patients with AAV from the UK, USA, and Canada were interviewed, using purposive sampling to include a range of disease manifestations and demographics. The project steering committee, including patient partners, designed the interview prompts and cues about AAV, its treatment, and impact on health-related quality of life. Interviews were transcribed and analysed to establish themes grounded in the data. A treatment-related code was used to focus analysis of salient themes related to glucocorticoid therapy. Fifty interviews were conducted. Individual themes related to therapy with glucocorticoids emerged from the data and were analysed. Three overarching themes emerged: (1) Glucocorticoids are effective at the time of diagnosis and during relapse, and withdrawal can potentiate a flare, (2) glucocorticoids are associated with salient emotional, physical, and social effects (depression, anxiety, irritation, weight gain and change in appearance, diabetes mellitus, effect on family and work); and (3) patient perceptions of balancing the risks and benefits of glucocorticoids. Patients identified the positive aspects of treatment with glucocorticoids; they are fast-acting and effective, but, they voiced concerns about adverse effects and the uncertainty of the dose-reduction process. These results may be informative in the development of novel glucocorticoid-sparing regimens.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/tratamento farmacológico , Glucocorticoides/uso terapêutico , Conhecimentos, Atitudes e Prática em Saúde , Pacientes/psicologia , Idoso , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/psicologia , Canadá , Progressão da Doença , Feminino , Glucocorticoides/efeitos adversos , Humanos , Entrevistas como Assunto , Masculino , Saúde Mental , Pessoa de Meia-Idade , Segurança do Paciente , Pesquisa Qualitativa , Qualidade de Vida , Recidiva , Indução de Remissão , Medição de Risco , Resultado do Tratamento , Reino Unido , Estados Unidos
18.
Med Care Res Rev ; 75(1): 46-65, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-27789628

RESUMO

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.


Assuntos
Continuidade da Assistência ao Paciente/organização & administração , Implementação de Plano de Saúde/métodos , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , United States Agency for Healthcare Research and Quality , Humanos , Estados Unidos
19.
Wound Repair Regen ; 25(5): 864-870, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-29220878

RESUMO

The purpose of this study was to explore perceptions among people with type 2 diabetes about foot ulcers and lower extremity amputations. This was a qualitative observational study utilizing open-ended, semistructured interviews of 39 people with diabetes who were purposively selected because they had either a foot ulcer (n = 19) or a lower extremity amputation (n = 20). Interviews were audio-recorded, deidentified, and entered into NVivo 10.0 for coding and analysis. Our integrated analytic approach combined inductively and deductively derived codes that were applied to all transcripts. Coded data were summarized and examined for patterns. Participants' description of the relationship between diabetes and their foot ulcer or amputation revealed a limited understanding of the disease process. Disruption and loss of independence was expressed whether the person had a foot ulcer or an amputation. Treatment recommendations for foot ulcers were viewed by most as extremely difficult. Amputation was a feared outcome, but some learned to adapt and, at times felt that the amputation enhanced their quality of life. Clinicians have assumed that a focus on limb salvage is preferred over a major amputation. However, because of the complexity of care requiring frequent healthcare provider visits, the frequency of care failure, the frequency of recurrence, and mortality associated with having had a foot ulcer, it may be more appropriate for clinicians to prioritize quality-of-life salvage. Foot ulcer treatment failure may be due to a lack of providers' understanding of the impact of treatment on a patient's life.


Assuntos
Amputação/estatística & dados numéricos , Diabetes Mellitus Tipo 2/complicações , Pé Diabético/cirurgia , Extremidade Inferior/cirurgia , Garantia da Qualidade dos Cuidados de Saúde , Qualidade de Vida , Cicatrização , Pé Diabético/epidemiologia , Pé Diabético/etiologia , Feminino , Humanos , Incidência , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Philadelphia/epidemiologia , Inquéritos e Questionários
20.
J Health Organ Manag ; 31(6): 630-646, 2017 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-29034825

RESUMO

Purpose The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. This transformation presents a challenge to many care delivery organizations. The purpose of this paper is to describe attributes shaping successful and unsuccessful practice transformation within four medical practice groups. Design/methodology/approach As part of a larger study of 25 practices transitioning into a PCMH, the current study focused on diabetes care and identified high- and low-improvement medical practices in terms of quantitative patient measures of glycosylated hemoglobin and qualitative assessments of practice performance. A subset of the top two high-improvement and bottom two low-improvement practices were identified as comparison groups. Semi-structured interviews were conducted with diverse personnel at these practices to investigate their experiences with practice transformation and data were analyzed using analytic induction. Findings Results show a variety of key attributes facilitating more successful PCMH transformation, such as empanelment, shared goals and regular meetings, and a clear understanding of PCMH transformation purposes, goals, and benefits, providing care/case management services, and facilitating patient reminders. Several barriers also exist to successful transformation, such as low levels of resources to handle financial expense, lack of understanding PCMH transformation purposes, goals, and benefits, inadequate training and management of technology, and low team cohesion. Originality/value Few studies qualitatively compare and contrast high and low performing practices to illuminate the experience of practice transformation. These findings highlight the experience of organizational members and their challenges in practice transformation while providing quality diabetes care.


Assuntos
Assistência Centrada no Paciente , Diabetes Mellitus/terapia , Metas , Humanos , Inovação Organizacional , Assistência Centrada no Paciente/organização & administração , Assistência Centrada no Paciente/normas , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Indicadores de Qualidade em Assistência à Saúde , Qualidade da Assistência à Saúde
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