Associations Between Practice Characteristics and Demonstration of Stage 1 Meaningful Use for the Electronic Health Record Incentive Program.

BACKGROUND: The Medicare and Medicaid meaningful use (MU) incentive programs promote adoption and "meaningful use" of certified electronic health records among hospitals and eligible providers in outpatient settings, with a goal of improving the quality of patient care. Despite the potential importance of MU for providers and patients, little is currently known about the practice characteristics that facilitate providers' demonstration of MU. This study examined whether selected practice characteristics were associated with providers' meeting Stage 1 MU objectives at the end of 1 year in a single large North Carolina integrated delivery system. METHODS: Our retrospective database analysis included all 702 eligible providers from 54 ambulatory care practices on the main campus of the University of North Carolina Health Care System. We assessed associations between providers' ability to meet Stage 1 MU objectives as of December 2012 and the following practice characteristics: practice specialty, size, and mix of Medicare- and Medicaid-eligible providers. RESULTS: The following practice characteristics were associated with providers' ability to meet MU objectives: primary care practices as compared to specialty practices (odds ratio [OR] = 2.49; 95% CI, 1.11-5.62), small practices as compared to medium-sized practices (OR = 0.29; 95% CI, 0.09-0.89), and the presence of only Medicare-eligible providers in the practice as compared to the presence of only Medicaid-eligible providers (OR = 6.48; 95% Cl, 1.08-38.97). LIMITATIONS: Because our sample was drawn from a single integrated delivery system, results may not be generalizable to all ambulatory practice settings. CONCLUSIONS: This study suggests that larger practices, primary care practices, and practices comprised of Medicare-eligible providers may be better able to meet MU objectives. Further research is needed to evaluate strategies that account for practice characteristics and other contextual factors in the MU implementation process.

Stage 1 of the meaningful use incentive program for electronic health records: a study of readiness for change in ambulatory practice settings in one integrated delivery system.

BACKGROUND: Meaningful Use (MU) provides financial incentives for electronic health record (EHR) implementation. EHR implementation holds promise for improving healthcare delivery, but also requires substantial changes for providers and staff. Establishing readiness for these changes may be important for realizing potential EHR benefits. Our study assesses whether provider/staff perceptions about the appropriateness of MU and their departments' ability to support MU-related changes are associated with their reported readiness for MU-related changes. METHODS: We surveyed providers and staff representing 47 ambulatory practices within an integrated delivery system. We assessed whether respondent's role and practice-setting type (primary versus specialty care) were associated with reported readiness for MU (i.e., willingness to change practice behavior and ability to document actions for MU) and hypothesized predictors of readiness (i.e., perceived appropriateness of MU and department support for MU). We then assessed associations between reported readiness and the hypothesized predictors of readiness. RESULTS: In total, 400 providers/staff responded (response rate approximately 25%). Individuals working in specialty settings were more likely to report that MU will divert attention from other patient-care priorities (12.6% vs. 4.4%, p = 0.019), as compared to those in primary-care settings. As compared to advanced-practice providers and nursing staff, physicians were less likely to have strong confidence in their department's ability to solve MU implementation problems (28.4% vs. 47.1% vs. 42.6%, p = 0.023) and to report strong willingness to change their work practices for MU (57.9% vs. 83.3% vs. 82.0%, p < 0.001). Finally, provider/staff perceptions about whether MU aligns with departmental goals (OR = 3.99, 95% confidence interval (CI) = 2.13 to 7.48); MU will divert attention from other patient-care priorities (OR = 2.26, 95% CI = 1.26 to 4.06); their department will support MU-related change efforts (OR = 3.99, 95% CI = 2.13 to 7.48); and their department will be able to solve MU implementation problems (OR = 2.26, 95% CI = 1.26 to 4.06) were associated with their willingness to change practice behavior for MU. CONCLUSIONS: Organizational leaders should gauge provider/staff perceptions about appropriateness and management support of MU-related change, as these perceptions might be related to subsequent implementation.

Assessing organizational capacity for achieving meaningful use of electronic health records.

BACKGROUND: Health care institutions are scrambling to manage the complex organizational change required for achieving meaningful use (MU) of electronic health records (EHR). Assessing baseline organizational capacity for the change can be a useful step toward effective planning and resource allocation. PURPOSE: The aim of this article is to describe an adaptable method and tool for assessing organizational capacity for achieving MU of EHR. Data on organizational capacity (people, processes, and technology resources) and barriers are presented from outpatient clinics within one integrated health care delivery system; thus, the focus is on MU requirements for eligible professionals, not eligible hospitals. METHODS: We conducted 109 interviews with representatives from 46 outpatient clinics. FINDINGS: Most clinics had core elements of the people domain of capacity in place. However, the process domain was problematic for many clinics, specifically, capturing problem lists as structured data and having standard processes for maintaining the problem list in the EHR. Also, nearly half of all clinics did not have methods for tracking compliance with their existing processes. Finally, most clinics maintained clinical information in multiple systems, not just the EHR. The most common perceived barriers to MU for eligible professionals included EHR functionality, changes to workflows, increased workload, and resistance to change. PRACTICE IMPLICATIONS: Organizational capacity assessments provide a broad institutional perspective and an in-depth clinic-level perspective useful for making resource decisions and tailoring strategies to support the MU change effort for eligible professionals.

The influence of literacy on patient-reported experiences of diabetes self-management support.

BACKGROUND: Variability in disease-related outcomes may relate to how patients experience self-management support in clinical settings. OBJECTIVES: The purpose of this study was to identify factors associated with experiences of self-management support during primary care encounters. METHODS: A cross-sectional survey was conducted of 208 patients seen in a multidisciplinary diabetes program in an academic medicine clinic. Multiple regression analysis was used to test associations between patient-rated experiences of self-management support (Patient Assessment of Chronic Illness Care) and race, gender, insurance status, literacy, duration of diabetes, and intensity of care management. RESULTS: The Patient Assessment of Chronic Illness Care ratings decreased with age (r = -.235, p = .001), were higher for women than for men (3.95 vs. 3.65, t = 2.612, p= .010), and were greater for those with more education (F= 3.927, p = .009) and greater literacy skills (t = 3.839, p< .001). The ratings did not vary between racial (t = -1.108, p = .269) or insurance (F = 1.045, p = .374) groups and were unaffected by the duration of diabetes (r= .052, p = .466) and the intensity of care management (F = 1.028, p = .360). In multivariate models, literacy was the only variable contributing significantly to variation in self-management support ratings. DISCUSSION: Even when considering the objective intensity of health services delivered, literacy was the sole variable contributing to differences in patient ratings of self-management support. Although conclusions are limited by the cross-sectional nature of this study, the results emphasize the need to consider literacy when developing and communicating treatment plans requiring self-management skills.

The Diabetes Literacy and Numeracy Education Toolkit (DLNET): materials to facilitate diabetes education and management in patients with low literacy and numeracy skills.

PURPOSE: Diabetes self-management education is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care. METHODS: To address this potential barrier to successful diabetes teaching and counseling, the authors developed the Diabetes Literacy and Numeracy Education Toolkit (DLNET). CONCLUSION: The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and used by all members of the multidisciplinary diabetes care team. The material's content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. Although designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Association of numeracy and diabetes control.

BACKGROUND: The influence of a patient's quantitative skills (numeracy) on the management of diabetes is only partially understood. OBJECTIVE: To examine the association between diabetes-related numeracy and glycemic control and other diabetes measurements. DESIGN: Cross-sectional survey. SETTING: 2 primary care and 2 diabetes clinics at 3 medical centers. PARTICIPANTS: 398 adult patients with type 1 or type 2 diabetes mellitus enrolled between March 2004 and November 2005. MEASUREMENTS: Health literacy, general numeracy, and diabetes-related numeracy assessed by using the Rapid Estimate of Adult Literacy in Medicine; the Wide Range Achievement Test, 3rd edition; and the Diabetes Numeracy Test (DNT), respectively. The primary outcome was most recent level of hemoglobin A1c. Additional measurements were diabetes knowledge, perceived self-efficacy of diabetes self-management, and self-management behaviors. RESULTS: The median DNT score was 65% (interquartile range, 42% to 81%). Common errors included misinterpreting glucose meter readings and miscalculating carbohydrate intake and medication dosages. Lower DNT scores were associated with older age, nonwhite race, fewer years of education, lower reported income, lower literacy and general numeracy skills, lower perceived self-efficacy, and selected self-management behaviors. Patients scoring in the lowest DNT quartile (score <42%) had a median hemoglobin A1c level of 7.6% (interquartile range, 6.5% to 9.0%) compared with 7.1% (interquartile range, 6.3% to 8.1%) in those scoring in the highest quartile (P = 0.119 for trend). A regression analysis adjusted for age, sex, race, income, and other factors found a modest association between DNT score and hemoglobin A1c level. LIMITATION: Causality cannot be determined in this cross-sectional study, especially with its risk for unmeasured confounding variables. CONCLUSION: Poor numeracy skills were common in patients with diabetes. Low diabetes-related numeracy skills were associated with worse perceived self-efficacy, fewer self-management behaviors, and possibly poorer glycemic control.

Use of patient flow analysis to improve patient visit efficiency by decreasing wait time in a primary care-based disease management programs for anticoagulation and chronic pain: a quality improvement study.

BACKGROUND: Patients with chronic conditions require frequent care visits. Problems can arise during several parts of the patient visit that decrease efficiency, making it difficult to effectively care for high volumes of patients. The purpose of the study is to test a method to improve patient visit efficiency. METHODS: We used Patient Flow Analysis to identify inefficiencies in the patient visit, suggest areas for improvement, and test the effectiveness of clinic interventions. RESULTS: At baseline, the mean visit time for 93 anticoagulation clinic patient visits was 84 minutes (+/- 50 minutes) and the mean visit time for 25 chronic pain clinic patient visits was 65 minutes (+/- 21 minutes). Based on these data, we identified specific areas of inefficiency and developed interventions to decrease the mean time of the patient visit. After interventions, follow-up data found the mean visit time was reduced to 59 minutes (+/-25 minutes) for the anticoagulation clinic, a time decrease of 25 minutes (t-test 39%; p < 0.001). Mean visit time for the chronic pain clinic was reduced to 43 minutes (+/- 14 minutes) a time decrease of 22 minutes (t-test 34 %; p < 0.001). CONCLUSION: Patient Flow Analysis is an effective technique to identify inefficiencies in the patient visit and efficiently collect patient flow data. Once inefficiencies are identified they can be improved through brief interventions.

A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes.

PURPOSE: To assess the efficacy of a pharmacist-led, primary care-based, disease management program to improve cardiovascular risk factors and glycated hemoglobin (A(1C)) levels in vulnerable patients with poorly controlled diabetes. METHODS: A randomized controlled trial of 217 patients with type 2 diabetes and poor glycemic control (A(1C) level >or=8.0%) was conducted at an academic general medicine practice from February 2001 to April 2003. Intervention patients received intensive management from clinical pharmacists, as well as from a diabetes care coordinator who provided diabetes education, applied algorithms for managing glucose control and decreasing cardiovascular risk factors, and addressed barriers to care. Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider. Outcomes were recorded at baseline and at 6 and 12 months. Primary outcomes included blood pressure, A(1C) level, cholesterol level, and aspirin use. Secondary outcomes included diabetes knowledge, satisfaction, use of clinical services, and adverse events. RESULTS: For the 194 patients (89%) with 12-month data, the intervention group had significantly greater improvement than did the control group for systolic blood pressure (-9 mm Hg; 95% confidence interval [CI]: -16 to -3 mm Hg) and A(1C) level (-0.8%; 95% CI: -1.7% to 0%). Change in total cholesterol level was not significant. At 12 months, aspirin use was 91% in the intervention group versus 58% among controls (P <0.0001). Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients. There were no significant differences in use of clinical services or adverse events. CONCLUSION: Our comprehensive disease management program reduced cardiovascular risk factors and A(1C) levels among vulnerable patients with type 2 diabetes and poor glycemic control.

The Spoken Knowledge in Low Literacy in Diabetes scale: a diabetes knowledge scale for vulnerable patients.

PURPOSE: The purpose of this study was to develop and validate a new knowledge scale for patients with type 2 diabetes and poor literacy: the Spoken Knowledge in Low Literacy patients with Diabetes (SKILLD). METHODS: The authors evaluated the 10-item SKILLD among 217 patients with type 2 diabetes and poor glycemic control at an academic general medicine clinic. Internal reliability was measured using the Kuder-Richardson coefficient. Performance on the SKILLD was compared to patient socioeconomic status, literacy level, duration of diabetes, and glycated hemoglobin (A1C). RESULTS: Respondents' mean age was 55 years, and they had diabetes for an average of 8.4 years; 38% had less than a sixth-grade literacy level. The average score on the SKILLD was 49%. Less than one third of patients knew the signs of hypoglycemia or the normal fasting blood glucose range. The internal reliability of the SKILLD was good (0.72). Higher performance on the SKILLD was significantly correlated with higher income (r = 0.22), education level (r = 0.36), literacy status (r = 0.33), duration of diabetes (r = 0.30), and lower A1C (r = -0.16). When dichotomized, patients with low SKILLD scores (< or = 50%) had significantly higher A1C (11.2% vs 10.3%, P < .01). This difference remained significant when adjusted for covariates. CONCLUSION: The SKILLD demonstrated good internal consistency and validity. It revealed significant knowledge deficits and was associated with glycemic control. The SKILLD represents a practical scale for patients with diabetes and low literacy.

The relationship between literacy and glycemic control in a diabetes disease-management program.

PURPOSE: This study examined the role of literacy in patients with poorly controlled diabetes who were participating in a diabetes management program that included low-literacy-oriented interventions. METHODS: A before-after analysis was performed of a pharmacist-led diabetes management program for 159 patients with type 2 diabetes and poor glycemic control (hemoglobin A1c [A1C] > or = 8.0%). Clinic-based pharmacists offered one-to-one education and medication management for these patients using techniques that did not require high literacy. Literacy was measured by the Rapid Estimate of Adult Literacy in Medicine (REALM) test and dichotomized at the 6th-grade level. The A1C values were collected prior to enrollment, at enrollment, and approximately 6 months after enrollment. RESULTS: Of the 111 patients with follow-up data, 55% had literacy levels at the 6th-grade level or below. Lower literacy was more common among African Americans, older patients, and patients who required medication assistance. There was no significant relationship between literacy status and A1C prior to enrollment or at enrollment. Over the 6-month study period, patients with low and high literacy had similar improvements in A1C. CONCLUSIONS: This diabetes care program, which used individualized teaching with low-literacy techniques, significantly improved A1C values independent of literacy status.

Development and pilot testing of a disease management program for low literacy patients with heart failure.

UNLABELLED: Development and pilot testing of a disease management program for low literacy patients with heart failure. BACKGROUND: Randomized trials have shown that disease management programs can reduce hospitalizations and improve symptoms for patients with congestive heart failure. We sought to create and pilot test such a program for patients with low literacy skills. METHODS: We used focus groups and individual cognitive response interviews (CRIs) to develop an educational booklet for low literacy patients with heart failure. We incorporated the booklet into a disease management intervention that also included an initial individualized 1-h educational session and scheduled supportive phone calls that were tapered over 6 weeks. We then conducted a 3-month before-after study on patients with low literacy skills (<9th grade literacy level) in a university internal medicine clinic to test the acceptability and efficacy of our program. Outcomes of interest included heart failure-related knowledge, self-care behavior and heart failure-related symptoms measured on the Minnesota Living with Heart Failure (MLwHF) scale. RESULTS: Twenty-five patients were enrolled and 23 (92%) completed 3-month follow-up. Mean age was 60 years (range 35-74), 60% were men, 60% were African-American, and 74% had household income under $15,000 per year. The median reading level was fifth grade with 32% reading at or below the third grade level. Mean knowledge score at baseline was 67% and did not improve after the intervention. The proportion of patients reporting weighing themselves daily increased from 32% at baseline to 100% at 12 weeks. Mean improvement on the MLwHF scale was 9.9 points over the 3-month trial (95% CI: 0.5, 19.2), which corresponds to an improvement in one class on the New York Heart Association heart failure scale. CONCLUSION: A heart failure disease management program designed specifically for patients with low literacy skills is acceptable and is associated with improvement in self-care behavior and heart failure related symptoms.

Pharmacist-led, primary care-based disease management improves hemoglobin A1c in high-risk patients with diabetes.

We developed and evaluated a comprehensive pharmacist-led, primary care-based diabetes disease management program for patients with Type 2 diabetes and poor glucose control at our academic general internal medicine practice. The primary goal of this program was to improve glucose control, as measured by hemoglobin A1c (HbA1c). Clinic-based pharmacists offered support to patients with diabetes through direct teaching about diabetes, frequent phone follow-up, medication algorithms, and use of a database that tracked patient outcomes and actively identified opportunities to improve care. From September 1999, to May 2000, 159 subjects were enrolled, and complete follow-up data were available for 138 (87%) patients. Baseline HbA1c averaged 10.8%, and after an average of 6 months of intervention, the mean reduction in HbA1c was 1.9 percentage points (95% confidence interval, 1.5-2.3). In predictive regression modeling, baseline HbA1c and new onset diabetes were associated with significant improvements in HbA1c. Age, race, gender, educational level, and provider status were not significant predictors of improvement. In conclusion, a pharmacist-based diabetes care program integrated into primary care practice significantly reduced HbA1c among patients with diabetes and poor glucose control.

Influence of patient literacy on the effectiveness of a primary care-based diabetes disease management program.

CONTEXT: Low literacy is an important barrier for patients with diabetes, but interventions to address low literacy have not been well examined. OBJECTIVE: To examine the role of literacy on the effectiveness of a comprehensive disease management program for patients with diabetes. DESIGN, SETTING, AND PARTICIPANTS: Analysis of the influence of literacy on glycemic control and systolic blood pressure using data from a randomized controlled trial (conducted from February 2001 through April 2003) of a comprehensive diabetes management program. Participants were 217 patients aged 18 years or older with type 2 diabetes and poor glycemic control (glycosylated hemoglobin [HbA1c] levels > or =8.0%) and presenting to a US academic general internal medicine practice. INTERVENTIONS: All communication to patients was individualized and delivered to enhance comprehension among patients with low literacy. Intervention patients received intensive disease management from a multidisciplinary team. Control patients received an initial management session and continued with usual care. MAIN OUTCOME MEASURES: Achievement of goal HbA1c levels and systolic blood pressure at 12-month follow-up for control and intervention patients stratified by literacy status. RESULTS: Complete 12-month data were available for 193 patients (89%). Among patients with low literacy, intervention patients were more likely than control patients to achieve goal HbA1c levels (< or =7.0%) (42% vs 15%, respectively; adjusted odds ratio [OR], 4.6; 95% confidence interval [CI], 1.3 to 17.2; P = .02). Patients with higher literacy had similar odds of achieving goal HbA1c levels regardless of intervention status (24% vs 23%; adjusted OR, 1.0; 95% CI, 0.4 to 2.5; P = .98). Improvements in systolic blood pressure were similar by literacy status. CONCLUSIONS: Literacy may be an important factor for predicting who will benefit from an intervention for diabetes management. A diabetes disease management program that addresses literacy may be particularly beneficial for patients with low literacy, and increasing access to such a program could help reduce health disparities.

Diabetes educators' knowledge, opinions and behaviors regarding periodontal disease and diabetes.

PURPOSE: The purpose of this study was to determine certified diabetes educators' (CDE) knowledge, behaviors and opinions about periodontal disease and diabetes. METHODS: A 33 item questionnaire was distributed to CDEs who provide counseling and education services to patients with diabetes. Questions were open and closed-ended and Likert-scale. A total of 298 CDEs participated in the survey. Descriptive statistics were utilized. RESULTS: Most (62%) agreed that CDEs need to collaborate with dental professionals in disease management and 84% indicated interest in an oral health component being added to their continuing education. Only 20% felt confident in providing an oral health screening to their patients, while 51% discussed oral health with their patients and 64% said they have referred a patient to a dentist within the past year. Most (79%) have not received formal oral health education. CONCLUSION: The findings indicate that CDEs are aware of and agree that there is a link between oral health and systemic health and that collaboration with the dental profession would be a positive outcome for their patients, as would oral health topics being added to their continuing education courses. By introducing inter-professional collaboration between dental professionals and CDEs, and adding an oral health component to CE courses, CDEs' ability to educate their patients regarding the oral/systemic link could improve.

North Carolina internists' and endocrinologists' knowledge, opinions, and behaviors regarding periodontal disease and diabetes: need and opportunity for interprofessional education.

The aim of this study was to determine the knowledge and practice behaviors of one state's internists and endocrinologists who treat patients with any type of diabetes. A thirty-five-item questionnaire was mailed to 1,000 internists and 115 endocrinologists in North Carolina. Questions were open and closed ended and Likert-scaled. Descriptive statistics and bivariate analysis were utilized. The response rate was 34 percent (N=378). The overall usable response rate was 23 percent (N=254). Over half of the respondents (66 percent) were males. Internists' and endocrinologists' knowledge about periodontal disease was high. The majority of the respondents agreed that physicians should be taught about periodontal disease (88 percent) and should be trained to screen for periodontal disease in their patients (78 percent). However, when asked if they are confident in providing an oral health screening for their patients, the responses were evenly distributed from strongly agree to strongly disagree. This study suggests that internists and endocrinologists have some knowledge about oral health and believe that there is a link between periodontal disease and diabetes mellitus; however, the majority do not have sufficient familiarity with the studies that link periodontal disease and diabetes mellitus. They agree with the idea of collaboration with dental professionals to reduce the number of patients at risk for developing periodontal disease. Perhaps the time is conducive to promote interprofessional education and collaboration between medical and dental health care providers to prepare for the future increase in patient and treatment needs.

Addressing literacy and numeracy to improve diabetes care: two randomized controlled trials.

OBJECTIVE: Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes. RESEARCH DESIGN AND METHODS: In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C >or=7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction. RESULTS: At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention -1.50 [95% CI -1.80 to -1.02]; control -0.80 [-1.10 to -0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction. CONCLUSIONS: A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention.