Primary care physicians' perceptions of barriers and facilitators to management of chronic kidney disease: A mixed methods study.

BackgroundGiven the high prevalence of chronic kidney disease (CKD), primary care physicians (PCPs) frequently manage early stage CKD. Nonetheless, there are challenges in providing optimal CKD care in the primary care setting. This study sought to understand PCPs' perceptions of barriers and facilitators to the optimal management of CKD.Study designMixed methods study.Settings and participantsCommunity-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC and San Francisco, CA.MethodologyWe used a self-administered questionnaire and conducted 4 focus groups of PCPs (n = 8 PCPs/focus group) in each city to identify key barriers and facilitators to management of patients with CKD in primary care.Analytic approachWe conducted descriptive analyses of the survey data. Major themes were identified from audio-recorded interviews that were transcribed and coded by the research team.ResultsOf 32 participating PCPs, 31 (97%) had been in practice for >10 years, and 29 (91%) practiced in a non-academic setting. PCPs identified multiple barriers to managing CKD in primary care including at the level of the patient (e.g., low awareness of CKD, poor adherence to treatment recommendations), the provider (e.g., staying current with CKD guidelines), and the health care system (e.g., inflexible electronic medical record, limited time and resources). PCPs desired electronic prompts and lab decision support, concise guidelines, and healthcare financing reform to improve CKD care.ConclusionsPCPs face substantial but modifiable barriers in providing care to patients with CKD. Interventions that address these barriers and promote facilitative tools may improve PCPs' effectiveness and capacity to care for patients with CKD

Annotated Bibliography: Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement.

The ambulatory care setting is an increasingly important component of the patient safety conversation. Inpatient safety is the primary focus of the vast majority of safety research and interventions, but the ambulatory setting is actually where most medical care is administered. Recent attention has shifted toward examining ambulatory care in order to implement better health care quality and safety practices. This annotated bibliography was created to analyze and augment the current literature on ambulatory care practices with regard to patient safety and quality improvement. By providing a thorough examination of current practices, potential improvement strategies in ambulatory care health care settings can be suggested. A better understanding of the myriad factors that influence delivery of patient care will catalyze future health care system development and implementation in the ambulatory setting

Emergency Department Clinicians’ Attitudes Toward Opioid Use Disorder and Emergency Department-initiated Buprenorphine Treatment: A Mixed-Methods Study

Introduction: Emergency department (ED) visits related to opioid use disorder (OUD) have increased nearly twofold over the last decade. Treatment with buprenorphine has been demonstrated to decrease opioid-related overdose deaths. In this study, we aimed to better understand ED clinicians’ attitudes toward the initiation of buprenorphine treatment in the ED.Methods: We performed a mixed-methods study consisting of a survey of 174 ED clinicians (attending physicians, residents, and physician assistants) and semi-structured interviews with 17 attending emergency physicians at a tertiary-care academic hospital.Results: A total of 93 ED clinicians (53% of those contacted) completed the survey. While 80% of respondents agreed that buprenorphine should be administered in the ED for patients requesting treatment, only 44% felt that they were prepared to discuss medication for addiction treatment. Compared to clinicians with fewer than five years of practice, those with greater experience were less likely to approve of ED-initiated buprenorphine. In our qualitative analysis, physicians had differing perspectives on the role that the ED should play in treating OUD. Most physicians felt that a buprenorphine-based intervention in the ED would be feasible with institutional support, including training opportunities, protocol support within the electronic health record, counseling and support staff, and a robust referral system for outpatient follow-up.Conclusion: ED clinicians’ perception of buprenorphine varied by years of practice and training level. Most ED clinicians did not feel prepared to initiate buprenorphine in the ED. Qualitative interviews identified several addressable barriers to ED-initiated buprenorphine

Improving Patient Satisfaction with the Virtual Handoff Process through the Utilization of Educational Pamphlets in the Emergency Department

Boarding patients in the emergency room while waiting to transfer the patient to the proper unit can be harmful to clinical care and have significant financial opportunity costs. At one local hospital it was found that on average patients were being boarded in the emergency room (ED) for approximately 85 minutes waiting to be transferred. Several barriers that caused this delay were found including, delay in room cleaning, nurse staff shortage, and inability to give report to the nurse receiving the patient. In an attempt to combat this delay which may be caused by a difficulty in giving patient report, this organization is rolling out a virtual bedside handoff process. While virtual technology is not a new concept, there are many patients that may not be comfortable with the technology. The purpose of the evidence-based project was to provide a written educational pamphlet that details the how’s and why’s of the virtual handoff process to the patient to be given upon admission. The goal of the educational pamphlet was to increase the patients’ satisfaction with the process. A pre-survey was given to a group of patients after they experienced the virtual handoff process to assess their comfort level. These results were compared to the post-survey results of patients that received the educational pamphlet prior to experiencing the virtual handoff process. Ten pre-surveys and seven post-surveys were analyzed utilizing SPSS and descriptive statistics. The analysis concluded that the participants who received the educational pamphlet felt more prepared for the virtual handoff process

The Electronic Health Record Scorecard: A Measure of Utilization and Communication Skills

As the adoption rate of electronic health records (EHRs) in the United States continues to grow, both providers and patients will need to adapt to the reality of a third actor being present during the visit encounter. The purpose of this project is to provide insight on “best” practice patterns for effective communication and efficient use of the EHR in the clinical practice setting. Through the development of a comprehensive scorecard, this project assessed current status of EHR use and communication skills among health care providers in various clinical practice settings. Anticipated benefits of this project are increased comfortability in interfacing with the EHR and increased satisfaction on the part of the provider as well as the patient. Serving as a benchmark, this assessment has the potential to help guide future health information technology development, training, and education for both students and health care providers

Nursing Home Implementation of Health Information Technology: Review of the Literature Finds Inadequate Investment in Preparation, Infrastructure, and Training.

Health information technology (HIT) is increasingly adopted by nursing homes to improve safety, quality of care, and staff productivity. We examined processes of HIT implementation in nursing homes, impact on the nursing home workforce, and related evidence on quality of care. We conducted a literature review that yielded 46 research articles on nursing homes' implementation of HIT. To provide additional contemporary context to our findings from the literature review, we also conducted semistructured interviews and small focus groups of nursing home staff (n = 15) in the United States. We found that nursing homes often do not employ a systematic process for HIT implementation, lack necessary technology support and infrastructure such as wireless connectivity, and underinvest in staff training, both for current and new hires. We found mixed evidence on whether HIT affects staff productivity and no evidence that HIT increases staff turnover. We found modest evidence that HIT may foster teamwork and communication. We found no evidence that the impact of HIT on staff or workflows improves quality of care or resident health outcomes. Without initial investment in implementation and training of their workforce, nursing homes are unlikely to realize potential HIT-related gains in productivity and quality of care. Policy makers should consider creating greater incentives for preparation, infrastructure, and training, with greater engagement of nursing home staff in design and implementation

Evaluating diverse electronic consultation programs with a common framework.

BackgroundElectronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth. We sought to identify gaps in knowledge related to the implementation of electronic consultation programs and develop a set of shared evaluation measures to promote further diffusion.MethodsUsing a case study approach, we apply the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) and the Quadruple Aim frameworks of evaluation to examine electronic consultation implementation across diverse delivery systems. Data are from 4 early adopter healthcare delivery systems (San Francisco Health Network, Mayo Clinic, Veterans Administration, Champlain Local Health Integration Network) that represent varied organizational structures, care for different patient populations, and have well-established multi-specialty electronic consultation programs. Data sources include published and unpublished quantitative data from each electronic consultation database and qualitative data from systems' end-users.ResultsOrganizational drivers of electronic consultation implementation were similar across the systems (challenges with timely and/or efficient access to specialty care), though unique system-level facilitators and barriers influenced reach, adoption and design. Effectiveness of implementation was consistent, with improved patient access to timely, perceived high-quality specialty expertise with few negative consequences, garnering high satisfaction among end-users. Data about patient-specific clinical outcomes are lacking, as are policies that provide guidance on the legal implications of electronic consultation and ideal remuneration strategies.ConclusionA core set of effectiveness and implementation metrics rooted in the Quadruple Aim may promote data-driven improvements and further diffusion of successful electronic consultation programs

Roles and recommendations from primary care physicians towards managing low-risk breast cancer survivors in a shared-care model with specialists in Singapore-a qualitative study.

BackgroundBreast cancer is prevalent and has high cure rates. The resultant increase in numbers of breast cancer survivors (BCS) may overwhelm the current oncology workforce in years to come. We postulate that primary care physicians (PCPs) could play an expanded role in comanaging survivors, provided they are given the appropriate tools and training to do so.ObjectiveTo explore the perspectives of PCPs towards managing BCS in a community-based shared-care programme with oncologists.MethodsEleven focus groups and six in-depth interviews were conducted with seventy PCPs recruited by purposive sampling. All sessions were audio-recorded, transcribed verbatim and coded by three independent investigators. Thematic data analysis was performed and the coding process facilitated by NVivo 12.ResultsMajority of PCPs reported currently limited roles in managing acute and non-cancer issues, optimizing comorbidities and preventive care. PCPs aspired to expand their role to include cancer surveillance, risk assessment and addressing unmet psychosocial needs. PCPs preferred to harmonize cancer survivorship management of their primary care patients who are also BCS, with defined role distinct from oncologists. Training to understand the care protocol, enhancement of communication skills, confidence and trust were deemed necessary. PCPs proposed selection criteria of BCS and adequacy of their medical information; increased consultation time; contact details and timely access to oncologists (if needed) in the shared-care programme.ConclusionsPCPs were willing to share the care of BCS with oncologists but recommended role definition, training, clinical protocol, resources and access to oncologist's consultation to optimize the programme implementation

Can This Marriage Be Saved?

Market forces in health care are paradoxically pulling physicians and hospitals apart and together at the same time. What are these forces and trends? Is the long-standing marriage of interdependence and productivity between them destined to fail, or can it be saved and even strengthened by emerging delivery and governance models in the so-called "market revolution" of consumer-driven health care? What are the implications for health care policy and practice? These are issues we explore in this Arizona Health Futures Policy Primer

Access Update, October 2010

Monthly newsletter for the Iowa Department of Public Healt