Browsing by Subject "health services research"
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Item Open Access Are Well-Informed Potential Trial Participants More Likely to Participate?(Journal of empirical research on human research ethics : JERHRE, 2017-12) de Oliveira, Lucas Lentini Herling; Vissoci, Joao Ricardo Nickenig; Machado, Wagner de Lara; Rodrigues, Clarissa G; Limkakeng, Alexander TBearing in mind the importance of the informed consent, flaws in this process may be a barrier to participants' recruitment. Our objective was to determine the relationship between the degree of comprehension of the informed consent document plus the importance given to individual elements by potential participants of a hypothetical trial and their willingness to participate in such trials. We performed an Online Survey simulating an emergency department trial recruitment, posteriorly evaluating participants' ratings of importance and self-assessed comprehension of specific topics of the informed consent document. Only 10% of the sample read the entire document. Some specific topics were associated with willingness to participate in the hypothetical trial, but simple composite additive scores of comprehension and importance were not. We concluded that participants in general do not read the entire informed consent document and that importance given to specific topics may influence willingness to participate.Item Open Access Healthcare Resource Utilization for Chronic Rhinosinusitis in Older Adults.(Healthcare (Basel, Switzerland), 2021-06-25) Jang, David W; Lee, Hui-Jie; Huang, Ryan J; Cheng, Jeffrey; Abi Hachem, Ralph; Scales, Chuck DObjectives
Chronic rhinosinusitis (CRS) is a common and costly health problem in the United States. While often associated with younger adults, CRS can affect the elderly. As the aging population increases in the United States, the cost burden of CRS in older adults is important to assess. The objective of this study is to characterize healthcare resource utilization (HCRU) and healthcare expenditure (HCE) for CRS in this population.Methods
Patients meeting criteria for CRS with three years of continuous data were identified on IBM® Marketscan Research Databases over a five-year period (2013-2017). Medication utilization, outpatient visits, surgery, and expenditures related to CRS were assessed for older adults (>65) and compared with other age groups. As a secondary analysis, multivariable generalized linear models were utilized to compare HCE while adjusting for baseline medication utilization.Results
A total of 238,825 patients met the inclusion criteria, of which 20,927 were older adults. Older adults had the highest overall prevalence of nasal polyps (10%) and asthma (16%) among adult groups. Surgery rate was lower than other adult groups, but medication utilization was the highest. Mean overall HCE at two years was highest in older adults (USD 2545 vs. 2298 in young adults). However, HCE was highest for the young adult group after adjusting for baseline medication usage.Conclusion
Older adults had a higher rate of CRS-related co-morbidities as well as the highest CRS-related medication utilization and unadjusted two-year HCE. Although the reasons for this are unclear, possibilities include greater disease severity and preference for medical versus surgical management. HCE for CRS is expected to increase as the aging population grows.Item Open Access Impact of Insurance Status on Outcomes and Use of Rehabilitation Services in Acute Ischemic Stroke: Findings From Get With The Guidelines-Stroke.(J Am Heart Assoc, 2016-11-14) Medford-Davis, Laura N; Fonarow, Gregg C; Bhatt, Deepak L; Xu, Haolin; Smith, Eric E; Suter, Robert; Peterson, Eric D; Xian, Ying; Matsouaka, Roland A; Schwamm, Lee HBACKGROUND: Insurance status affects access to care, which may affect health outcomes. The objective was to determine whether patients without insurance or with government-sponsored insurance had worse quality of care or in-hospital outcomes in acute ischemic stroke. METHODS AND RESULTS: Multivariable logistic regressions with generalized estimating equations stratified by age under or at least 65 years were adjusted for patient demographics and comorbidities, presenting factors, and hospital characteristics to determine differences in in-hospital mortality and postdischarge destination. We included 589 320 ischemic stroke patients treated at 1604 US hospitals participating in the Get With The Guidelines-Stroke program between 2012 and 2015. Uninsured patients with hypertension, high cholesterol, or diabetes mellitus were less likely to be taking appropriate control medications prior to stroke, to use an ambulance to arrive to the ED, or to arrive early after symptom onset. Even after adjustment, the uninsured were more likely than the privately insured to die in the hospital (<65 years, OR 1.33 [95% CI 1.22-1.45]; ≥65 years OR 1.54 [95% CI 1.34-1.75]), and among survivors, were less likely to go to inpatient rehab (<65 OR 0.63 [95% CI 0.6-0.67]; ≥65 OR 0.56 [95% CI 0.5-0.63]). In contrast, patients with Medicare and Medicaid were more likely to be discharged to a Skilled Nursing Facility (<65 years OR 2.08 [CI 1.96-2.2]; OR 2.01 [95% CI 1.91-2.13]; ≥65 years OR 1.1 [95% CI 1.07-1.13]; OR 1.41 [95% CI 1.35-1.46]). CONCLUSIONS: Preventative care prior to ischemic stroke, time to presentation for acute treatment, access to rehabilitation, and in-hospital mortality differ by patient insurance status.Item Open Access Implementation challenges to patient safety in Guatemala: a mixed methods evaluation.(BMJ quality & safety, 2021-05-26) Hall, Bria J; Puente, Melany; Aguilar, Angie; Sico, Isabelle; Orozco Barrios, Monica; Mendez, Sindy; Baumgartner, Joy Noel; Boyd, David; Calgua, Erwin; Lou-Meda, Randall; Ramirez, Carla C; Diez, Ana; Tello, Astrid; Sexton, J Bryan; Rice, HenryBackground
Little is known about factors affecting implementation of patient safety programmes in low and middle-income countries. The goal of our study was to evaluate the implementation of a patient safety programme for paediatric care in Guatemala.Methods
We used a mixed methods design to examine the implementation of a patient safety programme across 11 paediatric units at the Roosevelt Hospital in Guatemala. The safety programme included: (1) tools to measure and foster safety culture, (2) education of patient safety, (3) local leadership engagement, (4) safety event reporting systems, and (5) quality improvement interventions. Key informant staff (n=82) participated in qualitative interviews and quantitative surveys to identify implementation challenges early during programme deployment from May to July 2018, with follow-up focus group discussions in two units 1 year later to identify opportunities for programme modification. Data were analysed using thematic analysis, and integrated using triangulation, complementarity and expansion to identify emerging themes using the Consolidated Framework for Implementation Research. Salience levels were reported according to coding frequency, with valence levels measured to characterise the degree to which each construct impacted implementation.Results
We found several facilitators to safety programme implementation, including high staff receptivity, orientation towards patient-centredness and a desire for protocols. Key barriers included competing clinical demands, lack of knowledge about patient safety, limited governance, human factors and poor organisational incentives. Modifications included use of tools for staff recognition, integration of education into error reporting mechanisms and designation of trained champions to lead unit-based safety interventions.Conclusion
Implementation of safety programmes in low-resource settings requires recognition of facilitators such as staff receptivity and patient-centredness as well as barriers such as lack of training in patient safety and poor organisational incentives. Embedding an implementation analysis during programme deployment allows for programme modification to enhance successful implementation.Item Open Access Implications of practice setting on clinical outcomes and efficiency of care in the delivery of physical therapy services.(J Orthop Sports Phys Ther, 2014-12) Childs, John D; Harman, Jeffrey S; Rodeghero, Jason R; Horn, Maggie; George, Steven ZSTUDY DESIGN: Retrospective analysis of episodes of care. OBJECTIVE: To assess the implications of practice setting (hospital outpatient settings versus private practice) on clinical outcomes and efficiency of care in the delivery of physical therapy services. BACKGROUND: Many patients with musculoskeletal conditions benefit from care provided by physical therapists. The majority of physical therapists deliver services in either a private practice setting or in a hospital outpatient setting. There have not been any recent studies comparing whether clinical outcomes or efficiency of care differ based on practice setting. METHODS: Practices that use the Focus On Therapeutic Outcomes, Inc system were surveyed to determine the specific type of setting in which outcomes were collected in patients with musculoskeletal impairments. Patient outcome data over 12 months (2011-2012) were extracted from the database and analyzed to identify differences in the functional status achieved and the efficiency of the care delivery process between private practices and hospital outpatient settings. RESULTS: The data suggest that patients experience more efficient care when receiving physical therapy in hospital outpatient settings compared to private practice settings, as demonstrated by 3.1 points of greater improvement in functional status over 2.9 fewer physical therapy visits. However, the difference in improvement between settings is less than the minimum clinically important difference of 9 points in functional status outcome score. CONCLUSION: In this cohort, our data suggest that more efficient care was delivered in the hospital outpatient setting compared to the private practice setting. However, we cannot conclude that care delivered in the hospital setting is more cost-effective, because it is possible that any difference in efficiency of care favoring the hospital outpatient setting is more than offset by higher costs of care.Item Open Access Linkage between theory-based measurement of organizational readiness for change and lessons learned conducting quality improvement-focused research.(Learning health systems, 2017-04) Jackson, George L; Roumie, Christianne L; Rakley, Susan M; Kravetz, Jeffrey D; Kirshner, Miriam A; Del Monte, Pamela S; Bowen, Michael E; Oddone, Eugene Z; Weiner, Bryan J; Shaw, Ryan J; Bosworth, Hayden BOrganizations have different levels of readiness to implement change in the patient care process. The Hypertension Telemedicine Nurse Implementation Project for Veterans (HTN-IMPROVE) is an example of an innovation that seeks to enhance delivery of care for patients with hypertension. We describe the link between organizational readiness for change (ORC), assessed as the project began, and barriers and facilitators occurring during the process of implementing a primary care innovation. Each of 3 Veterans Affairs medical centers provided a half-time nurse and implemented a nurse-delivered, telephone-based self-management support program for patients with uncontrolled hypertension. As the program was starting, we assessed the ORC and factors associated with ORC. On the basis of consensus of medical center and research partners, we enumerated implementation process barriers and facilitators. The primary ORC barrier was unclear long-term commitment of nursing to provide continued resources to the program. Three related barriers included the need to address: (1) competing organizational demands, (2) differing mechanisms to integrate new interventions into existing workload, and (3) methods for referring patients to disease and self-management support programs. Prior to full implementation, however, stakeholders identified a high level of commitment to conduct nurse-delivered interventions fully using their skills. There was also a significant commitment from the core implementation team and a desire to improve patient outcomes. These facilitators were observed during the implementation of HTN-IMPROVE. As demonstrated by the link between barriers to and facilitators of implementation anticipated though the evaluation of ORC and what was actually observed during the process of implementation, this project demonstrates the practical utility of assessing ORC prior to embarking on the implementation of significant new clinical innovations.Item Open Access Multicomponent interventions for enhancing primary care: a systematic review.(The British journal of general practice : the journal of the Royal College of General Practitioners, 2021-01) Jimenez, Geronimo; Matchar, David; Koh, Gerald Choon-Huat; Car, JosipBackground
Many countries have implemented interventions to enhance primary care to strengthen their health systems. These programmes vary widely in features included and their impact on outcomes.Aim
To identify multiple-feature interventions aimed at enhancing primary care and their effects on measures of system success - that is, population health, healthcare costs and utilisation, patient satisfaction, and provider satisfaction (quadruple-aim outcomes).Design and setting
Systematic review and narrative synthesis.Method
Electronic, manual, and grey-literature searches were performed for articles describing multicomponent primary care interventions, providing details of their innovation features, relationship to the '4Cs' (first contact, comprehensiveness, coordination, and continuity), and impact on quadruple-aim outcomes. After abstract and full-text screening, articles were selected and their quality appraised. Results were synthesised in a narrative form.Results
From 37 included articles, most interventions aimed to improve access, enhance incentives for providers, provide team-based care, and introduce technologies. The most consistent improvements related to increased primary care visits and screening/preventive services, and improved patient and provider satisfaction; mixed results were found for hospital admissions, emergency department visits, and expenditures. The available data were not sufficient to link interventions, achievement of the 4Cs, and outcomes.Conclusion
Most analysed interventions improved some aspects of primary care while, simultaneously, producing non-statistically significant impacts, depending on the features of the interventions, the measured outcome(s), and the populations being studied. A critical research gap was revealed, namely, in terms of which intervention features to enhance primary care (alone or in combination) produce the most consistent benefits.Item Open Access Optimising mHealth helpdesk responsiveness in South Africa: towards automated message triage.(BMJ global health, 2018-01) Engelhard, Matthew; Copley, Charles; Watson, Jacqui; Pillay, Yogan; Barron, Peter; LeFevre, Amnesty ElizabethIn South Africa, a national-level helpdesk was established in August 2014 as a social accountability mechanism for improving governance, allowing recipients of public sector services to send complaints, compliments and questions directly to a team of National Department of Health (NDoH) staff members via text message. As demand increases, mechanisms to streamline and improve the helpdesk must be explored. This work aims to evaluate the need for and feasibility of automated message triage to improve helpdesk responsiveness to high-priority messages. Drawing from 65 768 messages submitted between October 2016 and July 2017, the quality of helpdesk message handling was evaluated via detailed inspection of (1) a random sample of 481 messages and (2) messages reporting mistreatment of women, as identified using expert-curated keywords. Automated triage was explored by training a naïve Bayes classifier to replicate message labels assigned by NDoH staff. Classifier performance was evaluated on 12 526 messages withheld from the training set. 90 of 481 (18.7%) NDoH responses were scored as suboptimal or incorrect, with median response time of 4.0 hours. 32 reports of facility-based mistreatment and 39 of partner and family violence were identified; NDoH response time and appropriateness for these messages were not superior to the random sample (P>0.05). The naïve Bayes classifier had average accuracy of 85.4%, with ≥98% specificity for infrequently appearing (<50%) labels. These results show that helpdesk handling of mistreatment of women could be improved. Keyword matching and naïve Bayes effectively identified uncommon messages of interest and could support automated triage to improve handling of high-priority messages.Item Open Access Population Segmentation Based on Healthcare Needs: Validation of a Brief Clinician-Administered Tool.(Journal of general internal medicine, 2021-01) Chong, Jia Loon; Matchar, David Bruce; Tan, Yuyang; Sri Kumaran, Shalini; Gandhi, Mihir; Ong, Marcus Eng Hock; Wong, Kok SengBackground
As populations age with increasingly complex chronic conditions, segmenting populations into clinically meaningful categories of healthcare and related service needs can provide healthcare planners with crucial information to optimally meet needs. However, while conventional approaches typically involve electronic medical records (EMRs), such records do not always capture information reliably or accurately.Objective
We describe the inter-rater reliability and predictive validity of a clinician-administered tool, the Simple Segmentation Tool (SST) for categorizing older individuals into one of six Global Impression (GI) segments and eight complicating factors (CFs) indicative of healthcare and related social needs.Design
Observational study ( ClinicalTrials.gov , number NCT02663037).Participants
Patients aged 55 years and above.Main measures
Emergency department (ED) subjects (between May and June 2016) had baseline SST assessment by two physicians and a nurse concurrently seeing the same individual. General medical (GM) ward subjects (February 2017) had a SST assessment by their principal physician. Adverse events (ED visits, hospitalizations, and mortality over 90 days from baseline) were determined by a blinded reviewer. Inter-rater reliability was measured using Cohen's kappa. Predictive validity was evaluated using Cox hazard ratios based on time to first adverse event.Key results
Cohen's kappa between physician-physician, service physician-nurse, and physician-nurse pairs for GI were 0.60, 0.71, and 0.68, respectively. Cox analyses demonstrated significant predictive validity of GI and CFs for adverse outcomes.Conclusions
With modest training, clinicians can complete a brief instrument to segment their patient into clinically meaningful categories of healthcare and related service needs. This approach can complement and overcome current limitations of EMR-based instruments, particularly with respect to whole-patient care.Trial registration
ClinicalTrials.gov Identifier: NCT02663037.Item Open Access Selecting, adapting, and sustaining programs in health care systems.(Journal of multidisciplinary healthcare, 2015-01) Zullig, Leah L; Bosworth, Hayden BPractitioners and researchers often design behavioral programs that are effective for a specific population or problem. Despite their success in a controlled setting, relatively few programs are scaled up and implemented in health care systems. Planning for scale-up is a critical, yet often overlooked, element in the process of program design. Equally as important is understanding how to select a program that has already been developed, and adapt and implement the program to meet specific organizational goals. This adaptation and implementation requires attention to organizational goals, available resources, and program cost. We assert that translational behavioral medicine necessitates expanding successful programs beyond a stand-alone research study. This paper describes key factors to consider when selecting, adapting, and sustaining programs for scale-up in large health care systems and applies the Knowledge to Action (KTA) Framework to a case study, illustrating knowledge creation and an action cycle of implementation and evaluation activities.