Lessons Learned Designing and Using an Online Discussion Forum for Care Coordinators in Primary Care.

While an increasing number of researchers are using online discussion forums for qualitative research, few authors have documented their experiences and lessons learned to demonstrate this method's viability and validity in health services research. We comprehensively describe our experiences, from start to finish, of designing and using an asynchronous online discussion forum for collecting and analyzing information elicited from care coordinators in Patient-Centered Medical Homes across the United States. Our lessons learned from each phase, including planning, designing, implementing, using, and ending this private online discussion forum, provide some recommendations for other health services researchers considering this method. An asynchronous online discussion forum is a feasible, efficient, and effective method to conduct a qualitative study, particularly when subjects are health professionals.

A typology of primary care workforce innovations in the United States since 2000.

PURPOSE: Innovative workforce models are being developed and implemented to meet the changing demands of primary care. A literature review was conducted to construct a typology of workforce models used by primary care practices. METHODS: Ovid Medline, CINAHL, and PsycInfo were used to identify published descriptions of the primary care workforce that deviated from what would be expected in the typical practice in the year 2000. Expert consultants identified additional articles that would not show up in a regular computerized search. Full texts of relevant articles were read and matrices for sorting articles were developed. Each article was reviewed and assigned to one of 18 cells in the matrices. Articles within each cell were then read again to identify patterns and develop an understanding of the full spectrum of workforce innovation within each category. RESULTS: This synthesis led to the development of a typology of workforce innovations represented in the literature. Many workforce innovations added personnel to existing practices, whereas others sought to retrain existing personnel or even develop roles outside the traditional practice. Most of these sought to minimize the impact on the existing practice roles and functions, particularly that of physicians. The synthesis also identified recent innovations which attempted to fundamentally transform the existing practice, with transformation being defined as a change in practice members' governing variables or values in regard to their workforce role. CONCLUSIONS: Most conceptualizations of the primary care workforce described in the literature do not reflect the level of innovation needed to meet the needs of the burgeoning numbers of patients with complex health issues, the necessity for roles and identities of physicians to change, and the call for fundamentally redesigned practices. However, we identified 5 key workforce innovation concepts that emerged from the literature: team care, population focus, additional resource support, creating workforce connections, and role change.

Effects of facilitated team meetings and learning collaboratives on colorectal cancer screening rates in primary care practices: a cluster randomized trial.

PURPOSE: The purpose of this study was to evaluate a primary care practice-based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates. METHODS: The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up. RESULTS: Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients' colorectal cancer screening rates. Qualitative analyses provide insights into practices' QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates. CONCLUSIONS: Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.

A Descriptive Analysis of Patients With Attempted Suicide at a Rural Level I Trauma Center.

Objectives: For patients with self-harm, suicide attempt, or suicide completion, the trauma bay is often the single point of contact. Regional differences and patterns exist for suicide that should be studied to enhance preventive strategies. Our goal was to critically evaluate the suicidal population of Southeast Georgia over a 9-year period. Methods: A retrospective review of our trauma database from January 2010 through December 2019 was conducted at a Level I Trauma Center. All ages were included. All patients arriving with attempted suicide or death due to a suicidal complication were included. Patients with deaths highly suspicious for suicide were also included. Exclusion criteria included accidental motor vehicle death, accidental generalized deaths, and accidental drowning. Age, gender, race, ethnicity, mechanism of injury (MOI), death rates, length of stay (LOS), injury severity score (ISS), home zip code, day of the week, transfer vs. from scene, location of injury, alcohol levels, and urine drug screening results were analyzed. Results: From 2010 to 2019, there were 381 total suicides with 260 survivals and 121 completions (mortality: 31.7%) at our Level I Trauma Center. The majority of suicides were performed by middle-aged White men with an average age of 40 years (SD: 17.2). This was true even if the White race was not the majority race in the patient's zip code. The majority of the time, these patients presented directly from the scene and, if the patient's suicide location was known, it usually took place at their home. Other common areas included secluded areas, such as wooded areas, and personal vehicles. Of the suicides, 11.6% were performed within the criminal justice system including jail and solitary confinement. The average LOS following admission was 7.51 days (SD: 22.1). The majority of suicides came from the metro Savannah district, which has higher unemployment and poverty rates than other parts of our study area. Gun violence was the most common MOI for suicide (75%). If suicide was attempted via a penetrating mechanism including glass, knife, or gun, there was an increased rate of death when compared to our general data (38% vs. 31%). When the gun mechanisms were analyzed as a group, there was a 57% rate of death after arrival at the hospital. Acute alcohol intoxication was present in 56.6% of patients and 80 (21%) had drugs in their system. Conclusion: Our data demonstrate epidemiologic and socioeconomic trends in Southeast Georgia. This included increased alcohol intoxication, deaths related to gun use, and in a higher incidence of suicide among White males, including geographic locations where the White race is not the majority. Suicides and suicide attempts were also more common in areas with higher unemployment rates.

Factors influencing men's decisions regarding prostate cancer screening: a qualitative study.

Shared decision making is recommended before prostate cancer screening. Little is known regarding reasons why men choose to get or not get prostate cancer screening, particularly in white or Hispanic men. We conducted semi-structured in-depth interviews of 64 men, age 50 years and over, purposively sampled from men who were never screened for prostate cancer or who screened abnormal in northern New Jersey. Qualitative analysis was iterative using a grounded theory approach involving a series of immersion/crystallization cycles. Men who had abnormal PSA tests either actively sought out screening because of family history of prostate cancer or received their screening as part of a routine physical examination. Men who were never screened avoided testing primarily because they perceived they were at low risk due to lack of urinary symptoms, lack of family history of prostate cancer, or beliefs that healthy behaviors can prevent prostate cancer. Other reasons for not getting screened included: fear of cancer, embarrassment over digital rectal exam, confusion over the screening procedure, and skepticism over the benefits of screening. Some men were willing to get screened if structural barriers were removed, their doctor recommended it, or if they were prompted by urinary symptoms. None had discussions with physicians about potential risks of prostate cancer screening. Men received their health information through lay media, friends or family members. Educating men in the community through mass media about benefits and limitations of prostate cancer screening may be more effective to promote and facilitate shared decision making with their physicians.

The Annual Institutional Review-Key Performance Measures and Processes.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) requires sponsoring institutions to demonstrate effective oversight through an annual institutional review (AIR). The ACGME only requires 3 elements to be reported, and it is up to the discretion of the designated institutional official (DIO) whether other supporting information should be included. This leads to uncertainty and inconsistency for DIOs as they decide what to report. OBJECTIVE: We surveyed DIOs in an effort to provide national data on key performance indicators and other relevant components of the AIR process. METHODS: In July 2019, we conducted a national survey of 847 DIOs. The survey had 16 questions that explored basic institutional demographics, timelines, and processes for the AIR and key performance indicators. Written answers were grouped by similar responses, and we performed descriptive statistics on all variables to assess distributions of responses. We also explored associations between variables using cross-tabulation and chi-square statistics. RESULTS: A total of 267 DIOs responded to the survey (32% response rate). There were 7 institutional performance measures that achieved over 50% consensus. These reviews required the majority of DIOs (62%, 167 of 267) 5 to 20 hours to complete. Less than one-third of sponsoring institutions reported diversity data. The majority of DIOs (68%, 182 of 267) felt the AIR process added substantial value. CONCLUSIONS: This survey reports key performance measures and processes included by DIOs in the AIR. Our results show a wide range of institutional responses though consensus was achieved on 7 key performance measures.

Obesity, Race, and COVID-19 Mortality: Results from a Large Cohort Early in the Pandemic.

Background: Obesity has increased progressively in the United States and is a known risk factor for several diseases such as type 2 diabetes, coronary artery disease, stroke and hypertension. Amid the current pandemic, concerns have been raised about obesity as a risk factor for COVID-19 positive patients. The primary goal of this study was to explore the association between obesity and hospital mortality in COVID-19 patients. Our secondary objective was to explore the relationship between obesity and race on hospital mortality in COVID-19 patients. Methods: This was a cross-sectional, retrospective analysis using data from 186 hospitals from across the United States and the United Kingdom during the first quarter of 2020. Extraction provided data from 25,894 patients who were tested for COVID-19, of whom 2,977 were positive. Patients were stratified into standard WHO categories for BMI and by race. Results: Bivariate analysis revealed significant relationships between mortality and sex (p<0.001) When BMI was analyzed as a continuous variable, multivariate analysis revealed a significant influence of BMI on mortality (odds ratio=1.291, p<0.05). Conclusion: COVID-19 mortality was significantly related to BMI, age and select co-morbidities, but race/ethnicity was not a predictor of mortality when controlling for other variables.

Utilization of Patient-Controlled Analgesia Reduces Length of Stay of Sickle Cell Crisis Hospitalizations.

Background: Sickle cell crisis hospitalizations are emotionally and financially burdensome to patients and healthcare systems, and processes to decrease the frequency or length of stay of these crises should be examined. Methods: This is a multicenter retrospective hospital record review of sickle cell crisis hospitalizations as defined by ICD-10 codes (D57.1-4), from January 2016 through December 2019, examining inpatient medication administration records and length of stay among admitted adults aged 18-65 years. Patient controlled analgesia orders using morphine, hydromorphone, fentanyl and/or merperidine at any point of an admission (n=188) were compared to admissions without any patient-controlled analgesia orders (n=2,159). The primary end point was hospital length of stay in days. A secondary analysis examining patients with or without greater than four admissions was also conducted. Results: The 1,675 patients who met criteria comprised 2,347 sickle cell hospitalizations during the four years examined. Of those admissions, 188 had at least one patient-controlled analgesic documented in their chart and had an average length of stay of 4.54 days (SD 3.34). The 2,159 admissions without any patient-controlled analgesia had an average length of stay of 5.74 days (SD 4.64). The difference of 1.2 days between the groups was statistically significant (p≤0.0001) using a Wilcoxon signed-rank test. Conclusion: Among patients with sickle cell crises who required inpatient hospitalizations, the use of patient-controlled analgesia demonstrated a statistically significant reduction of 1.2 days in their total length of stay. These findings support potentially changing hospital protocols to increase patient-controlled analgesia utilization.

Self-report versus medical records for assessing cancer-preventive services delivery.

Accurate measurement of cancer-preventive behaviors is important for quality improvement, research studies, and public health surveillance. Findings differ, however, depending on whether patient self-report or medical records are used as the data source. We evaluated concordance between patient self-report and medical records on risk factors, cancer screening, and behavioral counseling among primary care patients. Data from patient surveys and medical records were compared from 742 patients in 25 New Jersey primary care practices participating at baseline in SCOPE (supporting colorectal cancer outcomes through participatory enhancements), an intervention trial to improve colorectal cancer screening in primary care offices. Sensitivity, specificity, and rates of agreement describe concordance between self-report and medical records for risk factors (personal or family history of cancer, smoking), cancer screening (breast, cervical, colorectal, prostate), and counseling (cancer screening recommendations, diet or weight loss, exercise, smoking cessation). Rates of agreement ranged from 41% (smoking cessation counseling) to 96% (personal history of cancer). Cancer screening agreement ranged from 61% (Pap and prostate-specific antigen) to 83% (colorectal endoscopy) with self-report rates greater than medical record rates. Counseling was also reported more frequently by self-report (83% by patient self-report versus 34% by medical record for smoking cessation counseling). Deciding which data source to use will depend on the outcome of interest, whether the data is used for clinical decision making, performance tracking, or population surveillance; the availability of resources; and whether a false positive or a false negative is of more concern.

Barriers and Facilitators to Expanding Roles of Medical Assistants in Patient-Centered Medical Homes (PCMHs).

BACKGROUND: Many primary care practices participating in patient-centered medical home (PCMH) transformation initiatives are expanding the work roles of their medical assistants (MAs). Little is known about attitudes of MAs or barriers and facilitators to these role changes. METHODS: Secondary data analysis of qualitative cross-case comparison study of 15 New Jersey primary care practices participating in a PCMH project during 2012 to 2013. Observation field notes and in-depth and key informant interviews (with physicians, office managers, staff and care coordinators) were iteratively analyzed using grounded theory. RESULTS: MA roles and responsibilities changed from a mostly reactive role, completing tasks dependent on physician orders during the patient visit and facilitating patient flow through the office, to a more proactive one, conducting previsit planning, engaging in the overall care for patients, and assisting with population management. MAs differed in their attitudes about increased responsibilities, with some welcoming the opportunity to take on expanded roles, others resenting their increased responsibilities, and some expressing insufficient understanding regarding why new tasks and procedures were being implemented. Major barriers to MA role shifts included 1) insufficient understanding of the PCMH concept, 2) lack of time for added responsibilities, 3) additional workload without additional compensation, 4) disparate levels of medical knowledge and training, 5) reluctance of clinicians to delegate tasks, 6) uncertainty in making new workflow changes routine, 7) staff turnover, and 8) change fatigue. MAs were more positive about their role shifts when they 1) understood how their responsibilities fit within broader PCMH practice transformation goals; 2) received formal training in new tasks; 3) had detailed protocols and standing orders; 4) initiated role changes with small, achievable goals; 5) had open communication with clinicians and practice leaders; and 5) received additional compensation or paths to career advancement. CONCLUSIONS: Practice leaders need to be conscious of obstacles when they increase expectations of MAs, and they must be willing to invest time and resources into developing their MA workforce. An environment that allows open dialog with MAs and rewards and compensation that recognizes their increased efforts will help make expansion of MA roles occur more smoothly and efficiently.

Facilitators and Barriers to Care Coordination in Patient-centered Medical Homes (PCMHs) from Coordinators' Perspectives.

BACKGROUND: Care coordinators are increasingly featured in patient-centered medical home (PCMH) projects, yet little research examines how coordinators themselves define and experience their role. This is the first study describing experiences of care coordinators across the US from their own perspectives. METHODS: This qualitative study used a 5-month private, online discussion forum to gather data from 25 care coordinators from PCMH practices representing diversity in practice size, setting, and type. Participants answered questions and interacted with one another, creating an online social learning collaborative while allowing for data collection for research. RESULTS: Coordinators identified barriers and facilitators in their work at the organization/system level, the interpersonal level, and the individual level. Some factors emerged as both barriers and facilitators, including the functionality of clinical information technology; the availability of community resources; interactions with clinicians and other health care facilities; interactions with patients; and self-care practices for mental health and wellness. Colocation and full integration into practices were other key facilitators, whereas excessive case loads and data management responsibilities were felt to be important barriers. CONCLUSIONS: While all the barriers and facilitators were important to performing coordinators' roles, relationship building materialized as key to effective care coordination, whether with clinicians, patients, or outside organizations. We discuss implications for practice and provide suggestions for further research.

The influence of family ties on men's prostate cancer screening, biopsy, and treatment decisions.

Extensive research has focused on understanding family dynamics of men with prostate cancer. However, little qualitative work has examined the role of family ties on men's prostate cancer decisions across the spectrum of screening, diagnosis, and treatment. Using data from a larger study, we qualitatively explored the influence of family ties on men's prostate cancer decisions. Semistructured interviews were conducted with men ages ≥50 (N = 64), and data were analyzed using a grounded theory approach and a series of immersion/crystallization cycles. Three major themes of spousal/family member influence were identified: (a) spousal/family member alliance marked by open communication and shared decision making, (b) men who actively opposed spouse/family member pressure and made final decisions themselves, and (c) men who yielded to spouse/family member pressure. Our findings provide insights into men's relational dynamics that are important to consider for the shared decision-making process across the prostate cancer spectrum.

Decision-making processes of patients who use the emergency department for primary care needs.

Emergency department (ED) use for non-urgent needs is widely viewed as a contributor to various health care system flaws and inefficiencies. There are few qualitative studies designed to explore the complexity of patients' decision-making process to use the ED vs. primary care alternatives. In this study, semi-structured interviews were conducted with 30 patients who were discharged from the low acuity area of a university hospital ED. A grounded theory approach including cycles of immersion/crystallization was used to identify themes and reportable interpretations. Patients reported multiple decision-making considerations that hinged on whether or not they knew about primary care options. A model is developed depicting the complexity and variation in patients' decision-making to use the ED. Optimizing health system navigation and use requires improving objective factors such as access and costs as well as subjective perceptions of patients' health care, which are also a prominent part of their decision-making process.

More black box to explore: how quality improvement collaboratives shape practice change.

BACKGROUND: Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in health care. Evidence of their effectiveness is limited, prompting calls to "open up the black box" to better understand how and why such collaboratives work. METHODS: We selected a cohort of 5 primary care practices that participated in a 6-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data that included audio recordings and field notes of QICs and practice-based team meetings. RESULTS: Three themes emerged from our analysis: (1) practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance; (2) a mix of content and media in the QIC program was important for reaching all participants; (3) resources offered at the QIC did little to spur practice change efforts. CONCLUSION: QICs offer a potentially powerful way of disseminating health care innovations through enhanced strategies for learning and change. Creating collaborative environments in which diverse participants learn, listen, reflect, and share together can enable them to take back to their own organizations key messages and change strategies that benefit them the most.

How team-based reflection affects quality improvement implementation: a qualitative study.

Quality improvement (QI) interventions in health care organizations have produced mixed results with significant questions remaining about how QI interventions are implemented. Team-based reflection may be an important element for understanding QI implementation. Extensive research has focused on individual benefits of reflection including links between reflection, learning, and change. There are currently no published studies that explore how team-based reflection impact QI interventions. We selected 4 primary care practices participating in a QI trial that used a facilitated, team-based approach to improve colorectal cancer screening rates. Trained facilitators met with a team of practice members for up to eleven 1-hour meetings. Data include audio-recorded team meetings and associated fieldnotes. We used a template approach to code transcribed data and an immersion/crystallization technique to identify patterns and themes. Three types of team-based reflection and how each mattered for QI implementation were identified: organizational reflection promoted buy-in, motivation, and feelings of inspiration; process reflection enhanced team problem solving and change management; and relational reflection enhanced discussions of relational dynamics necessary to implement desired QI changes. If QI interventions seek to make changes where collaboration and coordination of care is required, then deliberately integrating team-based reflection into interventions can provide opportunities to facilitate change processes.

Physicians as inclusive leaders: insights from a participatory quality improvement intervention.

The patient-centered medical home model of primary care requires increased collaboration in care delivery. Recent studies suggest that such a collaborative model of care is aided by physician leaders who practice an inclusive approach to leadership; however, they do not empirically demonstrate what such strategies look like in primary care settings, nor do they provide insights to help physician leaders capitalize on the benefits of such an approach. Our analysis offers extended case illustrations of 3 physician leadership behaviors that exemplify leadership inclusiveness (explicitly soliciting team input; engaging in participatory decision making; and facilitating the inclusion of non-team members) as well as 3 behaviors that are counter to inclusiveness. These 6 cases emerged from our analysis of 8 primary care practices that participated in a 3-month facilitated, team-based quality improvement intervention that encouraged leadership inclusiveness. Qualitative data include observational field notes, interviews, and audio-recorded quality improvement meetings. Through these exemplar and nonexemplar cases, we highlight successes and challenges physicians experienced in their collaborative attempts. Such insights may prove important to physicians, researchers, and policy makers alike as they determine how best to aid physician leaders who are being challenged to recreate themselves as facilitators of collaboration.

Physician recommendation and patient adherence for colorectal cancer screening.

BACKGROUND: Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings. METHODS: Data were analyzed from 975 patients, aged ≥50 years, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC. RESULTS: Patients reported high screening rates for CRC (59%). More than three fourths of patients reported either screening or having received a screening recommendation (82%). Men (P = .0425), nonsmokers (P = .0029), and patients who were highly educated (P = .0311) were more likely to receive a CRC screening recommendation. Patients more adhere to CRC screening recommendations were older adults (P < .0001), nonsmokers (P = .0005), those who were more highly educated (P = .0365), Hispanics (P = .0325), and those who were married (P < .0001). CONCLUSIONS: Community and academic primary care clinicians appropriately recommended screening to high-risk patients with familial risk factors. However, they less frequently recommended screening to others (ie, women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.

The role of the champion in primary care change efforts: from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP).

BACKGROUND: Change champions are important for moving new innovations through the phases of initiation, development, and implementation. Although research attributes positive health care changes to the help of champions, little work provides details about the champion role. METHODS: Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data, which included field notes of team meetings, interviews, and transcripts of facilitator meetings, from a sample of 8 practices. RESULTS: Our analysis yielded insights into the value of having 2 discrete types of change champions: (1) those associated with a specific project (project champions) and (2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes care processes. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing. CONCLUSIONS: Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions--both project and organizational change champions--are critical players in supporting both innovation-specific and transformative change efforts.