Racial and Ethnic Differences in Diabetes Care and Health Care Use and Costs

INTRODUCTION: Previous studies have shown racial and ethnic differences in diabetes complication rates and diabetes control. The objective of this study was to examine racial and ethnic differences in diabetes care and health care use and costs for adults with diabetes using a nationally representative sample of the U.S. noninstitutionalized civilian population. METHODS: We performed a cross-sectional analysis of the 2000 Medical Expenditure Panel Survey (MEPS) and its related Diabetes Care Survey. The respondents were adults (aged 18 years and older) with diabetes, including non-Hispanic whites, non-Hispanic African Americans, and Hispanics. Racial and ethnic differences were examined in diabetes process of care and health care use and costs using logistic regression, negative binomial regression, and ordinary least squares regression with log cost. RESULTS: Most of the outcomes in diabetes care management, treatment, and complications were not significantly different among race groups. After adjusting for socioeconomic and demographic characteristics, Hispanics were more likely to have eye problems than whites (odds ratio, 1.56; 95% confidence interval, 1.03–2.56). African Americans and Hispanics had lower total health care costs, lower ambulatory care costs, and lower prescription drug costs than whites (P < .01 for all). CONCLUSION: We found differences in ambulatory care and prescription drug fills among white, African American, and Hispanic adults with diabetes. However, most of the diabetes care measures were not significantly different among the three racial and ethnic groups. Understanding the reason outcomes do not differ when health care use and costs differ significantly should be a focus of future studies

Implementation of an audit with feedback knowledge translation intervention to promote medication error reporting in health care: a protocol

Abstract Background Health professionals strive to deliver high-quality care in an inherently complex and error-prone environment. Underreporting of medical errors challenges attempts to understand causative factors and impedes efforts to implement preventive strategies. Audit with feedback is a knowledge translation strategy that has potential to modify health professionals’ medical error reporting behaviour. However, evidence regarding which aspects of this complex, multi-dimensional intervention work best is lacking. The aims of the Safe Medication Audit Reporting Translation (SMART) study are to: 1. Implement and refine a reporting mechanism to feed audit data on medication errors back to nurses 2. Test the feedback reporting mechanism to determine its utility and effect 3. Identify characteristics of organisational context associated with error reporting in response to feedback Methods/design A quasi-experimental design, incorporating two pairs of matched wards at an acute care hospital, is used. Randomisation occurs at the ward level; one ward from each pair is randomised to receive the intervention. A key stakeholder reference group informs the design and delivery of the feedback intervention. Nurses on the intervention wards receive the feedback intervention (feedback of analysed audit data) on a quarterly basis for 12 months. Data for the feedback intervention come from medication documentation point-prevalence audits and weekly reports on routinely collected medication error data. Weekly reports on these data are obtained for the control wards. A controlled interrupted time series analysis is used to evaluate the effect of the feedback intervention. Self-report data are also collected from nurses on all four wards at baseline and at completion of the intervention to elicit their perceptions of the work context. Additionally, following each feedback cycle, nurses on the intervention wards are invited to complete a survey to evaluate the feedback and to establish their intentions to change their reporting behaviour. To assess sustainability of the intervention, at 6 months following completion of the intervention a point-prevalence chart audit is undertaken and a report of routinely collected medication errors for the previous 6 months is obtained. This intervention will have wider application for delivery of feedback to promote behaviour change for other areas of preventable error and adverse events.http://deepblue.lib.umich.edu/bitstream/2027.42/111741/1/13012_2015_Article_260.pd

Data for improvement and clinical excellence: protocol for an audit with feedback intervention in home care and supportive living

<p>Abstract</p> <p>Background</p> <p>Although considerable evidence exists about the effectiveness of audit coupled with feedback, very few audit-with-feedback interventions have been done in either home care or supportive living settings to date. With little history of audit and feedback in home care or supportive living there is potential for greater effects, at least initially. This study extends the work of an earlier study designed to assess the effects of an audit-with-feedback intervention. It will be delivered quarterly over a one-year period in seven home care offices and 11 supportive living sites. The research questions are the same as in the first study but in a different environment. They are as follows:</p> <p>1. What effects do feedback reports have on processes and outcomes over time?</p> <p>2. How do different provider groups in home care and supportive living sites respond to feedback reports based on quality indicator data?</p> <p>Methods</p> <p>The research team conducting this study includes researchers and decision makers in continuing care in the province of Alberta, Canada. The intervention consists of quarterly feedback reports in 19 home care offices and supportive living sites across Alberta. Data for the feedback reports are based on the Resident Assessment Instrument Home Care tool, a standardized instrument mandated for use in home care and supportive living environments throughout Alberta. The feedback reports consist of one page, printed front and back, presenting both graphic and textual information. Reports are delivered to all employees working in each site. The primary evaluation uses a controlled interrupted time-series design, both adjusted and unadjusted for covariates. The concurrent process evaluation includes observation, focus groups, and self-reports to assess uptake of the feedback reports. The project described in this protocol follows a similar intervention conducted in our previous study, Data for Improvement and Clinical Excellence--Long-Term Care. We will offer dissemination strategies and spread of the feedback report approach in several ways suited to various audiences and stakeholders throughout Alberta.</p> <p>Significance</p> <p>This study will generate knowledge about the effects of an audit with feedback intervention in home care and supportive living settings. Our dissemination activities will focus on supporting sites to continue to use the Resident Assessment Instrument data in their quality improvement activities.</p

Unregulated provider perceptions of audit and feedback reports in long-term care: cross-sectional survey findings from a quality improvement intervention

Abstract Background Audit with feedback is a moderately effective approach for improving professional practice in other health care settings. Although unregulated caregivers give the majority of direct care in long-term care settings, little is known about how they understand and perceive feedback reports because unregulated providers have not been directly targeted to receive audit with feedback in quality improvement interventions in long-term care. The purpose of this paper is to describe unregulated care providers’ perceptions of usefulness of a feedback report in four Canadian long-term care facilities. Methods We delivered monthly feedback reports to unregulated care providers for 13 months in 2009–2010. The feedback reports described a unit’s performance in relation to falls, depression, and pain as compared to eight other units in the study. Follow-up surveys captured participant perceptions of the feedback report. We conducted descriptive analyses of the variables related to participant perceptions and multivariable logistic regression to assess the association between perceived usefulness of the feedback report and a set of independent variables. Results The vast majority (80%) of unregulated care providers (n = 171) who responded said they understood the reports. Those who discussed the report with others and were interested in other forms of data were more likely to find the feedback report useful for making changes in resident care. Conclusions This work suggests that unregulated care providers can understand and feel positively about using audit with feedback reports to make changes to resident care. Further research should explore ways to promote fuller engagement of unregulated care providers in decision-making to improve quality of care in long-term care settings.http://deepblue.lib.umich.edu/bitstream/2027.42/112596/1/12877_2012_Article_825.pd

Assessing response bias from missing quality of life data: The Heckman method

BACKGROUND: The objective of this study was to demonstrate the use of the Heckman two-step method to assess and correct for bias due to missing health related quality of life (HRQL) surveys in a clinical study of acute coronary syndrome (ACS) patients. METHODS: We analyzed data from 2,733 veterans with a confirmed diagnosis of acute coronary syndromes (ACS), including either acute myocardial infarction or unstable angina. HRQL outcomes were assessed by the Short-Form 36 (SF-36) health status survey which was mailed to all patients who were alive 7 months following ACS discharge. We created multivariable models of 7-month post-ACS physical and mental health status using data only from the 1,660 survey respondents. Then, using the Heckman method, we modeled survey non-response and incorporated this into our initial models to assess and correct for potential bias. We used logistic and ordinary least squares regression to estimate the multivariable selection models. RESULTS: We found that our model of 7-month mental health status was biased due to survey non-response, while the model for physical health status was not. A history of alcohol or substance abuse was no longer significantly associated with mental health status after controlling for bias due to non-response. Furthermore, the magnitude of the parameter estimates for several of the other predictor variables in the MCS model changed after accounting for bias due to survey non-response. CONCLUSION: Recognition and correction of bias due to survey non-response changed the factors that we concluded were associated with HRQL seven months following hospital admission for ACS as well as the magnitude of some associations. We conclude that the Heckman two-step method may be a valuable tool in the assessment and correction of selection bias in clinical studies of HRQL

Use of an audit with feedback implementation strategy to promote medication error reporting by nurses

Aims and objectivesTo outline the development and effect of an audit with feedback implementation strategy that intended to increase the rate of voluntary medication error reporting by nurses.BackgroundMedication errors are a serious global health issue. Audit with feedback is a widely used implementation strategy that has potential to modify nurses’ reporting behaviour and improve medication error reporting rates.DesignQuasi‐experimental implementation study (fulfilling the TIDieR checklist) with two pairs of matched wards at a private hospital in Australia was conducted from March 2015–September 2016. One ward from each pair was randomised to either the intervention or control group.MethodNurses within intervention wards received audit with feedback on a quarterly basis over a 12‐month implementation period. Control wards underwent quarterly audits only (without feedback). Feedback consisted of a one‐page infographic poster, with content based on medication error data obtained from audits and the hospitals’ risk management system (RiskMan). The primary outcome—rate of medication errors reported per month—was determined in both groups at pre‐implementation, implementation and postimplementation phases. Differences between groups were compared using generalised linear mixed models with Poisson distribution and log link.ResultsA nonsignificant intervention effect was found for rate of medication errors reported per month. Interestingly, when combining data from both groups, a significant increasing time trend was observed for medication errors reported per month across pre‐implementation and implementation phases (80% increase).ConclusionsThe audit with feedback strategy developed in the present study did not effectively influence the voluntary reporting of medication errors by nurses.Relevance to clinical practiceDespite the lack of intervention effects, the use of a published checklist to optimise the reporting quality of this study will contribute to the field by furthering the understanding of how to enhance audit with feedback implementation strategies for nurses.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163422/2/jocn15447.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163422/1/jocn15447_am.pd

Developing educational competencies for dissemination and implementation research training programs: An exploratory analysis using card sorts

Abstract Background With demand increasing for dissemination and implementation (D&I) training programs in the USA and other countries, more structured, competency-based, and tested curricula are needed to guide training programs. There are many benefits to the use of competencies in practice-based education such as the establishment of rigorous standards as well as providing an additional metrics for development and growth. As the first aim of a D&I training grant, an exploratory study was conducted to establish a new set of D&I competencies to guide training in D&I research. Methods Based upon existing D&I training literature, the leadership team compiled an initial list of competencies. The research team then engaged 16 additional colleagues in the area of D&I science to provide suggestions to the initial list. The competency list was then additionally narrowed to 43 unique competencies following feedback elicited from these D&I researchers. Three hundred additional D&I researchers were then invited via email to complete a card sort in which the list of competencies were sorted into three categories of experience levels. Participants had previous first-hand experience with D&I or knowledge translation training programs in the past. Participants reported their self-identified D&I expertise level as well as the country in which their home institution is located. A mean score was calculated for each competency based on their experience level categorization. From these mean scores, beginner-, intermediate-, and advanced-level tertiles were created for the competencies. Results The card sort request achieved a 41 % response rate (n = 124). The list of 43 competencies was organized into four broad domains and sorted based on their experience level score. Eleven competencies were classified into the “Beginner” category, 27 into “Intermediate,” and 5 into “Advanced.” Conclusions Education and training developers can use this competency list to formalize future trainings in D&I research, create more evidence-informed curricula, and enable overall capacity building and accompanying metrics in the field of D&I training and research.http://deepblue.lib.umich.edu/bitstream/2027.42/113065/1/13012_2015_Article_304.pd

Understanding feedback report uptake: process evaluation findings from a 13-month feedback intervention in long-term care settings

Abstract Background Long-term care settings provide care to a large proportion of predominantly older, highly disabled adults across the United States and Canada. Managing and improving quality of care is challenging, in part because staffing is highly dependent on relatively non-professional health care aides and resources are limited. Feedback interventions in these settings are relatively rare, and there has been little published information about the process of feedback intervention. Our objectives were to describe the key components of uptake of the feedback reports, as well as other indicators of participant response to the intervention. Methods We conducted this project in nine long-term care units in four facilities in Edmonton, Canada. We used mixed methods, including observations during a 13-month feedback report intervention with nine post-feedback survey cycles, to conduct a process evaluation of a feedback report intervention in these units. We included all facility-based direct care providers (staff) in the feedback report distribution and survey administration. We conducted descriptive analyses of the data from observations and surveys, presenting this in tabular and graphic form. We constructed a short scale to measure uptake of the feedback reports. Our analysis evaluated feedback report uptake by provider type over the 13 months of the intervention. Results We received a total of 1,080 survey responses over the period of the intervention, which varied by type of provider, facility, and survey month. Total number of reports distributed ranged from 103 in cycle 12 to 229 in cycle 3, although the method of delivery varied widely across the period, from 12% to 65% delivered directly to individuals and 15% to 84% left for later distribution. The key elements of feedback uptake, including receiving, reading, understanding, discussing, and reporting a perception that the reports were useful, varied by survey cycle and provider type, as well as by facility. Uptake, as we measured it, was consistently high overall, but varied widely by provider type and time period. Conclusions We report detailed process data describing the aspects of uptake of a feedback report during an intensive, longitudinal feedback intervention in long-term care facilities. Uptake is a complex process for which we used multiple measures. We demonstrate the feasibility of conducting a complex longitudinal feedback intervention in relatively resource-poor long-term care facilities to a wider range of provider types than have been included in prior feedback interventions.http://deepblue.lib.umich.edu/bitstream/2027.42/110519/1/13012_2015_Article_208.pd

Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study

Abstract Background The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). Methods Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. Results We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. Conclusions Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.https://deepblue.lib.umich.edu/bitstream/2027.42/148315/1/12913_2019_Article_4012.pd