Emergency Medicine: Competencies for Youth Violence Prevention and Control

By any standard one wishes to apply, the impact of violence on the health and safety of the public is significant. The expression of violence among children in the United States has increased significantly during the modern era. Homicide and suicide are the second and third leading causes of death in youths 15-24 years of age. The emergency department (ED) is a common site for the care of these victims, and because victims often become assailants, the emergency care provider needs to know the epidemiology, treatment, and methods for prevention of youth violence in order to curtail the cycle. A multidisciplinary task force was convened by the Centers for Disease Control and Prevention (CDC)-funded Southern California Center of Academic Excellence on Youth Violence Prevention and the Keck School of Medicine at the University of Southern California to define competencies for health professionals in youth violence prevention and control. Three levels of competence were identified: the generalist level, which should be obtained by all health professionals; the specialist level, which should be obtained by health professionals such as emergency medicine providers, who frequently work with populations affected by violence; and a third, or scholar level, to be acquired by health professionals who wish to become experts not only in the care, but also in research and advocacy. This article reports the details of this group's efforts and applies them to emergency care provider education. These competencies should shape the development of curricula for the span of emergency medical training from emergency medical services scholastic training to postgraduate continuous medical education.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75259/1/aemj.9.9.947.pd

An evaluation of the spread and scale of PatientToc™ from primary care to community pharmacy practice for the collection of patient-reported outcomes: A study protocol

Background Medication non-adherence is a problem of critical importance, affecting approximately 50% of all persons taking at least one regularly scheduled prescription medication and costing the United States more than $100 billion annually. Traditional data sources for identifying and resolving medication non-adherence in community pharmacies include prescription fill histories. However, medication possession does not necessarily mean patients are taking their medications as prescribed. Patient-reported outcomes (PROs), measuring adherence challenges pertaining to both remembering and intention to take medication, offer a rich data source for pharmacists and prescribers to use to resolve medication non-adherence. PatientToc™ is a PROs collection software developed to facilitate collection of PROs data from low-literacy and non-English speaking patients in Los Angeles. Objectives This study will evaluate the spread and scale of PatientToc™ from primary care to community pharmacies for the collection and use of PROs data pertaining to medication adherence. Methods The following implementation and evaluation steps will be conducted: 1) a pre-implementation developmental formative evaluation to determine community pharmacy workflow and current practices for identifying and resolving medication non-adherence, potential barriers and facilitators to PatientToc™ implementation, and to create a draft implementation toolkit, 2) two plan-do-study-act cycles to refine an implementation toolkit for spreading and scaling implementation of PatientToc™ in community pharmacies, and 3) a comprehensive, theory-driven evaluation of the quality of care, implementation, and patient health outcomes of spreading and scaling PatientToc™ to community pharmacies. Expected impact This research will inform long-term collection and use of PROs data pertaining to medication adherence in community pharmacies

Experiences Applying Technology to Overcome Common Challenges in Pharmacy Practice-Based Research in the United States

Despite the importance of pharmacy practice-based research in generating knowledge that results in better outcomes for patients, health systems and society alike, common challenges to PPBR persist. Herein, we authors describe PPBR challenges our research teams have encountered, and our experiences using technology-driven solutions to overcome such challenges. Notably, limited financial resources reduce the time available for clinicians and researchers to participate in study activities; therefore, resource allocation must be optimized. We authors have also encountered primary data collection challenges due to unique data needs and data access/ownership issues. Moreover, we have experienced a wide geographic dispersion of study practices and collaborating researchers; a lack of trained, on-site research personnel; and the identification and enrollment of participants meeting study eligibility criteria. To address these PPBR challenges, we authors have begun to turn to technology-driven solutions, as described here

The Association of Health Literacy and Blood Pressure Reduction in a Cohort of Patients with Hypertension: The Heart Healthy Lenoir Trial

OBJECTIVE: Lower health literacy is associated with poorer health outcomes. Few interventions poised to mitigate the impact of health literacy in hypertensive patients have been published. We tested if a multilevel quality improvement intervention could differentially improve Systolic Blood Pressure (SBP) more so in patients with low vs. higher health literacy. METHODS: We conducted a non-randomized prospective cohort trial of 525 patients referred with uncontrolled hypertension. Stakeholder informed and health literacy sensitive strategies were implemented at the practice and patient level. Outcomes were assessed at 0, 6, 12, 18 and 24 months. RESULTS: At 12 months, the low and higher health literacy groups had statistically significant decreases in mean SBP (6.6 and 5.3 mmHg, respectively), but the between group difference was not significant (Δ 1.3 mm Hg, P=.067). At 24 months, the low and higher health literacy groups reductions were 8.1 and 4.6 mm Hg, respectively, again the between group difference was not significant (Δ 3.5 mm Hg, p = 0.25). CONCLUSIONS/PRACTICE IMPLICATIONS: A health literacy sensitive multi-level intervention may equally lower SBP in patients with low and higher health literacy. Practical health literacy appropriate tools and methods can be implemented in primary care settings using a quality improvement approach

Leveraging Practice-Based Research Networks to Accelerate Implementation and Diffusion of Chronic Kidney Disease Guidelines in Primary Care practices: A Prospective Cohort Study

Background Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices. Methods Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians. They received only monthly practice facilitation. The primary outcomes were adherence to primary care-relevant process-of-care recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Performance was determined retrospectively by medical records abstraction. Practice priority, change capacity, and care process content were measured before and after the interventions. Results Following the intervention, wave I practices increased the use of ACEIs/ARBs, discontinuation of NSAIDs, testing for anemia, and testing and/or treatment for vitamin D deficiency. Most were able to recruit two additional practices for wave II, and wave II practices also increased their use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency. Conclusions With some assistance, early adopter practices can facilitate the diffusion of evidence-based approaches to other practices. PBRNs are well-positioned to replicate this process for other evidence-based innovations

A cross-sectional study of provider and patient characteristics associated with outpatient disclosures of dietary supplement use

ObjectiveExplore patterns in patients' disclosures of supplement use and identify provider and patient characteristics associated with disclosures.MethodsCross-sectional study of 61 outpatient primary care, integrative medicine, and complementary medicine providers, and 603 of their patients. Primary outcomes were supplement disclosures (based on audio recorded office visits, post-visit patient surveys and medical record abstractions for the day of the visits).ResultsSeventy-nine percent of 603 patients reported on a post-visit survey that they took a total of 2107 dietary supplements. Of those taking supplements, 232 patients (48.6%) discussed at least one supplement with their provider on the day of their office visit. However, patients disclosed only 714 (33.9%) of the 2107 supplements they were taking. Patients more frequently disclosed supplement use when they saw providers who attributed greater importance to asking about supplements. Patient characteristics such as patient activation, number of medical conditions, and use of prescription medications were not associated with disclosure of supplement use.ConclusionsProvider rating of the importance of asking about supplements is a major factor prompting patients' disclosures of supplement use.Practice implicationsProvider-targeted interventions to encourage provider awareness about potential supplement-drug interactions are needed to increase disclosures about dietary supplement use

Leveraging Practice-Based Research Networks to Accelerate Implementation and Diffusion of Chronic Kidney Disease Guidelines in Primary Care practices: A Prospective Cohort Study

Background Four practice-based research networks (PBRNs) participated in a study to determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease by leveraging early adopter practices. Methods Motivated practices from four PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months during wave I of the study. Each wave I practice then recruited two additional practices (wave II), which received performance feedback and academic detailing and participated in monthly local learning collaboratives led by the wave I clinicians. They received only monthly practice facilitation. The primary outcomes were adherence to primary care-relevant process-of-care recommendations from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines. Performance was determined retrospectively by medical records abstraction. Practice priority, change capacity, and care process content were measured before and after the interventions. Results Following the intervention, wave I practices increased the use of ACEIs/ARBs, discontinuation of NSAIDs, testing for anemia, and testing and/or treatment for vitamin D deficiency. Most were able to recruit two additional practices for wave II, and wave II practices also increased their use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency. Conclusions With some assistance, early adopter practices can facilitate the diffusion of evidence-based approaches to other practices. PBRNs are well-positioned to replicate this process for other evidence-based innovations