A systematic review of health service interventions to reduce use of unplanned health care in rural areas

Rationale, aims and objectives: Use of unplanned health care has long been increasing, and not enough is known about which interventions may reduce use. We aimed to review the effectiveness of interventions to reduce the use of unplanned health care by rural populations. Methods: The method used was systematic review. Scientific databases (Medline, Embase and Central), grey literature and selected references were searched. Study quality and bias was assessed using Cochrane Risk of Bias and modified Newcastle Ottawa Scales. Results were summarized narratively. Results: A total of 2708 scientific articles, reports and other documents were found. After screening, 33 studies met the eligibility criteria, of which eight were randomized controlled trials, 13 were observational studies of unplanned care use before and after new practices were implemented and 12 compared intervention patients with non-randomized control patients. Eight of the 33 studies reported modest statistically significant reductions in unplanned emergency care use while two reported statistically significant increases in unplanned care. Reductions were associated with preventative medicine, telemedicine and targeting chronic illnesses. Cost savings were also reported for some interventions. Conclusion: Relatively few studies report on unscheduled medical care by specifically rural populations, and interventions were associated with modest reductions in unplanned care use. Future research should evaluate interventions more robustly and more clearly report the results

Provider Utilization of an Electronic Health Record Diagnostic and Statistical Manual V Criteria Evaluation Tool for Individuals with Attention Deficit Hyperactivity Disorder

AbstractIntroduction. Attention Deficit Hyperactivity Disorder (ADHD) is the most common neurobehavioral condition in children. Current guidelines recommend that Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria be used prior to diagnosis of ADHD. However, many providers are still using DSM-IV with the potential for inaccurate diagnosis. The use of a standardized electronic health record (EHR) template for ADHD that will serve as a reminder for providers to use DSM-V criteria. The objective of the project was to compare utilization of the DSM-V EHR evaluation tool with current documentation practice for screening ADHD. The project examined consistencies in ADHD screening documentation and conducted comparisons between different providers: physician (MD), advanced practice registered nurse (APRN), and physician assistant (PA) in relationship to screening for ADHD.Methods. Pre- and post-intervention design was used to evaluate documentation practices. Ten providers were given education on DSM-V criteria and instructions for screening template use. Providers’ documentation practices were collected at 3 months before DSM-V EHR template implementation (October 1- December 31, 2019) and 2 months after (January 16 – March 1, 2019). Demographic and clinical data of children both pre- and post-implementation were also collected from the EHR. Provider demographics were obtained from a pre-implementation survey. Descriptive statistics and Chi-square were used to characterize variable distributions and t-tests evaluated group comparisons between provider groups.Results. Provider (5 MDs and 5APRN/PAs) documentation practices were screened for children pre (n=57) and post (n=55) implementation. Children had a mean age of 9 � 3.7, predominantly males (75%), Hispanic (85%), and all children were covered by public insurance (100%). Some children (20-30%) required referral in both groups for further evaluation by a child psychiatrist. There was no statistical differences pre- and post-intervention related to DSM-V template use in ADHD screening. However, there were statistical differences between provider type with the APRN/PAs screening more frequently using the DSM-V template (n=4) than MDs (n= 0) (p=.009). Conclusion. Providers did not consistently use the DSM-V EHR template to screen children for ADHD. Future studies are needed to evaluate barriers to using the template, including practice preferences, openness to change, and other factors that may affect use of the EHR template

The Role of Mobile Health Technologies in Allergy Care:an EAACI Position Paper

Mobile health (mHealth) uses mobile communication devices such as smartphones and tablet computers to support and improve health-related services, data and information flow, patient self-management, surveillance, and disease management from the moment of first diagnosis to an optimized treatment. The European Academy of Allergy and Clinical Immunology created a task force to assess the state of the art and future potential of mHealth in allergology. The task force endorsed the "Be He@lthy, Be Mobile" WHO initiative and debated the quality, usability, efficiency, advantages, limitations, and risks of mobile solutions for allergic diseases. The results are summarized in this position paper, analyzing also the regulatory background with regard to the "General Data Protection Regulation" and Medical Directives of the European Community. The task force assessed the design, user engagement, content, potential of inducing behavioral change, credibility/accountability, and privacy policies of mHealth products. The perspectives of healthcare professionals and allergic patients are discussed, underlining the need of thorough investigation for an effective design of mHealth technologies as auxiliary tools to improve quality of care. Within the context of precision medicine, these could facilitate the change in perspective from clinician- to patient-centered care. The current and future potential of mHealth is then examined for specific areas of allergology, including allergic rhinitis, aerobiology, allergen immunotherapy, asthma, dermatological diseases, food allergies, anaphylaxis, insect venom, and drug allergy. The impact of mobile technologies and associated big data sets are outlined. Facts and recommendations for future mHealth initiatives within EAACI are listed

A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination personnel

Introduction & Importance: Effective, patient-centered care coordination has been shown to improve outcomes for children with special healthcare needs (CSHCN), who often have complex, long-term involvement with multiple service providers. Traumatic brain injury (TBI) can result in long-term physical, intellectual, social, and emotional disabilities that persist long after acute treatment. Yet, even though it is a chronic condition, TBI remains an area with scarce standardization and research surrounding the complex, long-term care coordination need in this population. The purpose of this scoping review is to summarize current research on outcomes in CSHCN after implementation of care coordinators, whether individual or teams, to inform future research for youth with TBI. Methods: OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination and CSHCN. Results: 31 articles met inclusion criteria. Outcomes for children and families were grouped into 5 major categories: healthcare utilization, cost of care, disease status, parent and child quality of life, and healthcare satisfaction and perception of care. Discussion: Implementation of care coordinators, whether in the form of individuals, dyads, or teams, resulted in overall positive outcomes for CSHCN and their families across all 5 major outcome domains. Future research should be focused on the efficacy of care coordinators differing in profession, qualifications, and educational attainment specifically for the unique needs of children with TBI. Additionally, the application of care coordination within medical homes should be further investigated to increase proactive, preventative care of children with TBI and further reduce reactive, need-based treatment only

Enhanced Primary Care Electronic Medical Record Education to Improve the Use of Patient Portals

abstract: Background: Health information technology (HIT) refers to the electronic health care systems organizations used to store, share and analyze healthcare information. A central component of the HIT infrastructure is an electronic health record (EMR) and although HIT has been shown to increase enthusiasm for patient care, decrease healthcare costs and improve patient outcomes overall utilization in the United States (US) remains low. Methods: At an urban primary care pediatric office located in the southwestern US, an educational quality improvement project for healthcare practice providers and front office staff was conducted to increase the utilization of the existing EMR-linked patient portal. The healthcare providers were asked to complete a pre- and post- survey evaluation of their knowledge and usage of the patient portal. Provider and patient portal data usage was collected over a five-month period, September 2019 to January 2020. Results: Data was analyzed using the Intellectus Statistics softwareTM. Significant results were found at the conclusion of the project in the number of active patient portal users, web-enabled, portal logins, labs published/viewed, messages sent, appointment reminders and Santovia utilization. At the end of the project no significance was found with messages received by the healthcare providers or staff through the patient portal. Survey results found significant differences between pre- and post- portal usage. No significance was found on providers’ knowledge on how to web-enable patients. Providers’ also demonstrated no significant change in their perceptions of the benefit in utilizing the portal in patient care after the educational intervention. Survey results allowed for additional analysis of commonly utilized portal functionalities, disease or health topics utilized in Santovia, and suggestions on how to make the use of the patient portal easier for providers. Implications for Health Care Providers: This quality improvement project found that implementation an EMR-linked patient portal requires a comprehensive practice approach with structured education sessions. Including all employees can improve patient portal utilization. This educational project resulted in significant increases in most portal functionalities within 5 months. Further practice change evaluations are needed to evaluate how to improve patient portal utilization with a larger group of participants in a variety of outpatient settings

Evaluation, Validation & Implementation of a Computerized Diagnostic Decision Support System in Primary Practice

Background: Medical diagnosis may be the most complex task attempted by humans. Studies estimate that 95% of diagnoses in outpatient care are accurate, implying that the annual rate of inaccurate diagnoses is 12 million in the US alone, with the potential for patient harm in about half. A well-researched differential might reduce inaccurate diagnoses by offering alternatives matching the patient’s symptoms. This study searched the literature for articles evaluating the diagnostic performance of commercially available computerized diagnostic decision support systems. This search led to selecting Isabel Pro, developed by Isabel Healthcare, Ltd. of Haslemere, UK. Evaluation and Validation: A computerized diagnostic decision support system should respond adequately to four questions: What is the “diagnostic retrieval accuracy”? Does it perform as well as clinicians? When provided with the differential, do clinicians improve diagnostic accuracy? Is it easily incorporated into routine practice? The project validated the diagnostic retrieval accuracy of Isabel Pro using 46 cases with a previously confirmed diagnosis. The confirmed diagnosis appeared in Isabel Pro’s differential in 24 cases (52.2%), outperforming even internal medicine faculty (47%). Using those 24 cases and the differentials produced, the author conducted a diagnostic challenge that involved 120 McGovern Medical School residents. The residents produced 406 diagnoses, of which 105 (25.9%) were correct without the differentials, and 37 were correct post-consultation, a 9.1% absolute improvement. In responses, 75.1% of the participants agreed the differentials would be helpful in routine practice, and 64.1% agreed they would consult the differentials if available. Implementation: The project successfully proposed Isabel Pro as a solution to UT practice leadership on September 16, 2021, and incorporated the system into the Epic EHR as a menu line link on November 30, 2021. This system-wide integration also included a QR code for downloading Isabel Pro to a mobile device. Usage of Isabel Pro in the practices of UTPhysicians began on December 8, 2021. Results: The project concluded data collection after 86 days on March 4, 2022, with usage showing a steady increase in the final three weeks. The project produced 73 unique users (37 faculty and 36 residents). The user survey responses showed 83.3% agreeing they would consult the differential generated by Isabel Pro if available at every patient encounter (+19.2% compared to the challenge survey) and 77.8% agreeing that the suggestions would be helpful in routine practice (+2.7% compared to the challenge survey). More than one-third (36.8%) responded that they changed their diagnosis in response to the differential. Limitations: Only usage statistics were analyzed; the system records no reason for the clinician discontinuing a diagnostic session. Only 20 participants responded out of 73 (27.4%), so even though the respondents represented a spread of experience levels, the results may not represent the total number of potential users. The project covered a limited period of 86 days. Conclusions: Diagnostic inaccuracy is a significant patient safety concern. Studies show that computerized diagnostic decision support systems improve diagnostic accuracy, but they are not wide implementation lags despite these findings. This project demonstrated the feasibility of implementing such a well-known system in academic medical practice. The responses to the surveys demonstrate favorable opinions about the system’s perceived usefulness. Active communication and dissemination programs may be essential to improve and sustain use

Pediatric Asthma Control Assessment Project

The purpose of the capstone project was to explore the efficacy of the ATAQ to assess for asthma control at each patient encounter. In addition, addressing asthma control at each care visit would improve asthma outcomes by implementing education that promotes asthma self-management. The goal of the capstone project was to improve asthma control assessment in the primary care setting and provide asthma education for children and the caregiver to improve asthma outcomes. The data analysis indicated asthma control improvement among subjects who received the asthma education intervention (p=0.011). In addition, there was a positive correlation with high ATAQ scores and an increase in reported HCU (p=0.770). Increased reported days of limited physical activities was significant (p=0.561) with high ATAQ scores. The data also indicated a moderately positive correlation with high ATAQ scores and increased reported numbers of missed school days/missed workdays by caregivers (p=0.435)

Building Medical Homes in State Medicaid and CHIP Programs

Presents strategies, best practices, and lessons learned from ten states' efforts to advance the medical home model of comprehensive and coordinated care in Medicaid and Children's Health Insurance Programs in order to improve quality and contain costs

Implementing Spirometry-Driven Evidence-Based Asthma Care in a Primary Care Practice

This project was a quality improvement initiative employing an educational intervention to increase the awareness and stress the importance of utilizing spirometry in the diagnosis, treatment, and management of asthma. Clinical support staff received training on how to perform spirometry and providers received education on the interpretation and utility of spirometry results to drive care to improve outcomes for clients with asthma. Project outcomes examined the self-rated confidence to perform and interpret spirometry before and after the intervention and the subsequent utilization pattern of office-based spirometry at the primary care clinic. For clinical support staff, the self-comfort level at performing spirometry increased by an average of 32.1% after the training session, and the average overall confidence level in ability to perform spirometry on clients in the imminent future was 74.8%. For providers, the self-reported comfort-level in their ability to interpret spirometry reports increased by an average of 30.8%. There was also an average overall 96.3% confidence in the providers’ perceptions of their ability to accurately interpret a spirogram in the imminent future following the educational session. In-office spirometry use from 2015 to 2016 increased by twofold. This primary care office utilized their spirometer as much during the one month following this project’s interventions than it did the entire 2015 fiscal year. Valuable experience was gained implementing this project and recommendations for future initiatives are explored. This document discusses the background information, problem statement, intervention, evaluation methods, outcomes, sustainability, and dissemination methods related to the project