Implementation and Effectiveness of Triggered Palliative Care Consults in Oncology

The overall objectives of this research were to: (1) determine whether triggered palliative care consultation (TPCC) could achieve effective consult implementation in oncology and (2) examine the effect of inpatient palliative care consults on health resource use (i.e., hospice discharge and 30-day readmissions). We used a mixed-methods research design of two distinct inpatient oncology services at UNC Hospital. Data sources included qualitative interviews and secondary data using the UNC Palliative Care Clinical Research Database linked to electronic medical record data from 2010 to 2016. The first study used a two-case study design of palliative care consult implementation in the medical oncology and gynecologic oncology services. Qualitative data were collected through in-person interviews with clinicians. Quantitative data on consult uptake were used to complement the qualitative findings. The study provided an in-depth understanding of organizational contextual factors associated with effective palliative care consult implementation and suggested refinements to organizational theory. The second study used difference-in-difference regression models to longitudinally examine the impact of two TPCC approaches on palliative care consult uptake and timeliness. TPCC supported by a single strategy was associated with greater consult uptake compared to usual care (aRR 1.45, p<.05), and TPCC supported by multiple strategies was associated with greater consult uptake compared to a single strategy (aRR 2.34, p<.001). TPCC did not significantly impact time to consult. The third study used multivariate regression with propensity score matching to examine associations among inpatient palliative care consultation, hospice use (discharge), and 30-day unplanned readmissions. The likelihood of having a 30-day readmission did not significantly differ between the palliative care consult and usual care groups. However, the palliative care consult group was significantly more likely than usual care to have a hospice discharge (aRR = 4.09, p<.001). The predicted probability of readmission was lower when palliative care consultation was combined with hospice discharge compared to consultation with discharge to non-hospice post-acute care or usual care (p<.001). In sum, TPCC improved consult implementation in oncology, and inpatient palliative care consults leading to hospice discharge resulted in reduced 30-day readmissions. Health care systems should consider the organizational context for implementation to identify optimal strategies for integrating palliative care consults into oncology and improving outcomes for cancer patients.Doctor of Philosoph

The Role of School Leaders in Creating a Learning Ecosystem Through School-Community Partnerships

This multi-method study examined survey and interview data collected from current K-12 school leaders in Rhode Island, New Hampshire, and Southeastern Massachusetts to determine the role school leaders play in creating a learning ecosystem through school-community partnerships. This study included three research questions that inquired about the degree to which principals believe school-community partnerships improve schools, the ways partnerships are currently developed, and the identification of factors and conditions that promote or inhibit partnerships. Data was collected in three phases, including survey responses from 25 school leaders, followed by interviews with five respondents, with the final phase consisting of document reviews to inform the development of two case study vignettes. Five themes emerged from the data: providing opportunities for students, staff, and family; aligning efforts and approaches; developing and maintaining relationships; sharing resources and building capital; and establishing strong public relations. Case study vignettes were then developed with the findings from the case studies detailing the perspectives and approaches of current school leaders in terms of school-community partnerships. Findings reveal that school leaders utilize partnerships that have a clear purpose, are connected to goals of the school, and that also provide opportunities for students, staff, and the community. Additional findings illustrate that school leaders built on already existing structures and relationships to develop and maintain partnerships, as well as, use approaches that are geared toward building social capital for their school community. Further findings also demonstrate that school leaders rely on planning and prioritization strategies as important supports for partnerships and that school leaders view partnerships as mechanisms to expand the messaging of their schools

2023-2024 Sound the Trumpets!

An evening of great trumpet music featuring master trumpeters, Vince DiMartino and Jason Dovel

Bragtown, Durham County, NC : an action-oriented community diagnosis : findings and next steps of action

Between October 2002 and April 2003, five students from the Health Behavior and Health Education department at the School of Public Health at the University of North Carolina at Chapel Hill worked with the help of a community member to conduct an Action Oriented Community Diagnosis (AOCD) in the Bragtown community of Durham County, North Carolina. The objective of this document is to summarize the UNC team’s research process and findings. To provide the reader with a clear perspective on the Bragtown community, the document begins by presenting background information on the boundaries, history, and demographics of the area. The next chapter describes the methods used by the UNC team to complete the diagnosis. The following two sections illustrate the themes and other findings that emerged from data collected through interviews with community members and service providers. Next is a description of the community forum, which was organized with the help of a planning committee comprised of community members and service providers. Finally, the UNC team presents a summary of conclusions and recommendations for individuals working in the Bragtown community and for future AOCD teams. Although Bragtown has struggled in the past to maintain a distinct identity, it is clear that the community has a rich history of working together for success. One indication that the community can be just as successful in the future is the desire of forum participants to create a community group called “Bragtown Neighbors,” which will work to improve the neighborhood. The UNC team enjoyed working in Bragtown and hopes that this document will demonstrate the strengths of the community, as well as provide a resource for “Bragtown Neighbors” and other groups or individuals.Master of Public Healt

Identifying barriers to evidence-based care for sickle cell disease: Results from the Sickle Cell Disease Implementation Consortium cross-sectional survey of healthcare providers in the USA

OBJECTIVES: Sickle cell disease (SCD) leads to chronic and acute complications that require specialised care to manage symptoms and optimise clinical results. The National Heart Lung and Blood Institute (NHLBI) evidence-based guidelines assist providers in caring for individuals with SCD, but adoption of these guidelines by providers has not been optimal. The objective of this study was to identify barriers to treating individuals with SCD. METHODS: The SCD Implementation Consortium aimed to investigate the perception and level of comfort of providers regarding evidence-based care by surveying providers in the regions of six clinical centres across the USA, focusing on non-emergency care from the providers\u27 perspective. RESULTS: Respondents included 105 providers delivering clinical care for individuals with SCD. Areas of practice were most frequently paediatrics (24%) or haematology/SCD specialist (24%). The majority (77%) reported that they were comfortable managing acute pain episodes while 63% expressed comfort with managing chronic pain. Haematologists and SCD specialists showed higher comfort levels prescribing opioids (100% vs 67%, p=0.004) and managing care with hydroxyurea (90% vs 51%, p=0.005) compared with non-haematology providers. Approximately 33% of providers were unaware of the 2014 NHLBI guidelines. Nearly 63% of providers felt patients\u27 medical needs were addressed while only 22% felt their mental health needs were met. CONCLUSIONS: A substantial number of providers did not know about NHLBI\u27s SCD care guidelines. Barriers to providing care for patients with SCD were influenced by providers\u27 specialty, training and practice setting. Increasing provider knowledge could improve hydroxyurea utilisation, pain management and mental health support

Impact of the COVID-19 pandemic on the implementation of mobile health to improve the uptake of hydroxyurea in patients with sickle cell disease: Mixed methods study

BACKGROUND: Hydroxyurea therapy is effective for reducing complications related to sickle cell disease (SCD) and is recommended by National Health Lung and Blood Institute care guidelines. However, hydroxyurea is underutilized, and adherence is suboptimal. We wanted to test a multilevel mobile health (mHealth) intervention to increase hydroxyurea adherence among patients and improve prescribing among providers in a multicenter clinical trial. In the first 2 study sites, participants were exposed to the early phases of the COVID-19 pandemic, which included disruption to their regular SCD care. OBJECTIVE: We aimed to describe the impact of the COVID-19 pandemic on the implementation of an mHealth behavioral intervention for improving hydroxyurea adherence among patients with SCD. METHODS: The first 2 sites initiated enrollment 3 months prior to the start of the pandemic (November 2019 to March 2020). During implementation, site A clinics shut down for 2 months and site B clinics shut down for 9 months. We used the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework to evaluate the implementation and effectiveness of the intervention. mHealth implementation was assessed based on patients\u27 daily app use. Adherence to hydroxyurea was calculated as the proportion of days covered (PDC) from prescription records over the first 12 and 24 weeks after implementation. A linear model examined the relationship between app usage and PDC change, adjusting for baseline PDC, lockdown duration, and site. We conducted semistructured interviews with patients, health care providers, administrators, and research staff to identify factors associated with mHealth implementation and effectiveness. We used a mixed methods approach to investigate the convergence of qualitative and quantitative findings. RESULTS: The percentage of patients accessing the app decreased after March 15, 2020 from 86% (n=55) to 70% (n=45). The overall mean PDC increase from baseline to week 12 was 4.5% (P=.32) and to week 24 was 1.5% (P=.70). The mean PDC change was greater at site A (12 weeks: 20.9%; P=.003; 24 weeks: 16.7%; P=.01) than site B (12 weeks: -8.2%; P=.14; 24 weeks: -10.3%; P=.02). After adjustment, PDC change was 13.8% greater in those with increased app use after March 15, 2020. Interview findings indicated that site B\u27s closure during COVID-19 had a greater impact, but almost all patients reported that the InCharge Health app helped support more consistent medication use. CONCLUSIONS: We found significant impacts of the early clinic lockdowns, which reduced implementation of the mHealth intervention and led to reduced patient adherence to hydroxyurea. However, disruptions were lower among participants who experienced shorter clinic lockdowns and were associated with higher hydroxyurea adherence. Investigation of added strategies to mitigate the effects of care interruptions during major emergencies (eg, patient coaching and health navigation) may insulate the implementation of interventions to increase medication adherence. TRIAL REGISTRATION: ClinicalTrials.gov NCT04080167; https://clinicaltrials.gov/ct2/show/NCT04080167. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/16319

African American women's perceptions of cancer clinical trials

Cancer clinical trials are important for resolving cancer health disparities for several reasons; however, clinical trial participation among African Americans is significantly lower than Caucasians. This study engaged focus groups of 82 female African American cancer survivors or cancer caregivers, including those in better resourced, more urban areas and less resourced, more rural areas. Informed by an integrated conceptual model, the focus groups examined perceptions of cancer clinical trials and identified leverage points that future interventions may use to improve enrollment rates. Study findings highlight variation in community knowledge regarding cancer clinical trials, and the importance of community education regarding clinical trials and overcoming historical stigma associated with clinical research specifically and the health care system more generally. Study participants commented on the centrality of churches in their communities, and thus the promise of the church as loci of such education. Findings also suggested the value of informed community leaders as community information sources, including community members who have a previous diagnosis of cancer and clinical trial experience. The sample size and location of the focus groups may limit the generalizability of the results. Since the women in the focus groups were either cancer survivors or caregivers, they may have different experiences than nonparticipants who lack the close connection with cancer. Trust in the health system and in one's physician was seen as important factors associated with patient willingness to enroll in clinical trials, and participants suggested that physicians who were compassionate and who engaged and educated their patients would build important trust requisite for patient participation in clinical trials

Elaborating on theory with middle managers’ experience implementing healthcare innovations in practice

Abstract Background The theory of middle managers’ role in implementing healthcare innovations hypothesized that middle managers influence implementation effectiveness by fulfilling the following four roles: diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. The theory also suggested several activities in which middle managers might engage to fulfill the four roles. The extent to which the theory aligns with middle managers’ experience in practice is unclear. We surveyed middle managers (n = 63) who attended a nursing innovation summit to (1) assess alignment between the theory and middle managers’ experience in practice and (2) elaborate on the theory with examples from middle managers’ experience overseeing innovation implementation in practice. Findings Middle managers rated all of the theory’s hypothesized four roles as “extremely important” but ranked diffusing and synthesizing information as the most important and selling innovation implementation as the least important. They reported engaging in several activities that were consistent with the theory’s hypothesized roles and activities such as diffusing information via meetings and training. They also reported engaging in activities not described in the theory such as appraising employee performance. Conclusions Middle managers’ experience aligned well with the theory and expanded definitions of the roles and activities that it hypothesized. Future studies should assess the relationship between hypothesized roles and the effectiveness with which innovations are implemented in practice. If evidence supports the theory, the theory should be leveraged to promote the fulfillment of hypothesized roles among middle managers, doing so may promote innovation implementation

A surveillance system for monitoring, public reporting, and improving minority access to cancer clinical trials

The Institute of Medicine (IOM) has recommended that each person with cancer should have access to clinical trials, which have been associated with improving care quality and disparities. With no effective enrollment monitoring system, patterns of trial enrollment remain unclear