Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health

Multilevel interventions are those that affect at least two levels of influence—for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health’s Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions

Validity and usefulness of members reports of implementation progress in a quality improvement initiative: findings from the Team Check-up Tool (TCT)

<p>Abstract</p> <p>Background</p> <p>Team-based interventions are effective for improving safety and quality of healthcare. However, contextual factors, such as team functioning, leadership, and organizational support, can vary significantly across teams and affect the level of implementation success. Yet, the science for measuring context is immature. The goal of this study is to validate measures from a short instrument tailored to track dynamic context and progress for a team-based quality improvement (QI) intervention.</p> <p>Methods</p> <p>Design: Secondary cross-sectional and longitudinal analysis of data from a clustered randomized controlled trial (RCT) of a team-based quality improvement intervention to reduce central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs).</p> <p>Setting: Forty-six ICUs located within 35 faith-based, not-for-profit community hospitals across 12 states in the U.S.</p> <p>Population: Team members participating in an ICU-based QI intervention.</p> <p>Measures: The primary measure is the Team Check-up Tool (TCT), an original instrument that assesses context and progress of a team-based QI intervention. The TCT is administered monthly. Validation measures include CLABSI rate, Team Functioning Survey (TFS) and Practice Environment Scale (PES) from the Nursing Work Index.</p> <p>Analysis: Temporal stability, responsiveness and validity of the TCT.</p> <p>Results</p> <p>We found evidence supporting the temporal stability, construct validity, and responsiveness of TCT measures of intervention activities, perceived group-level behaviors, and barriers to team progress.</p> <p>Conclusions</p> <p>The TCT demonstrates good measurement reliability, validity, and responsiveness. By having more validated measures on implementation context, researchers can more readily conduct rigorous studies to identify contextual variables linked to key intervention and patient outcomes and strengthen the evidence base on successful spread of efficacious team-based interventions. QI teams participating in an intervention should also find data from a validated tool useful for identifying opportunities to improve their own implementation.</p

What is the value and impact of quality and safety teams? A scoping review

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.</p> <p>Methods</p> <p>Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.</p> <p>Results</p> <p>Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.</p> <p>Conclusions</p> <p>Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.</p

Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research

No abstract available

A multi-level system quality improvement intervention to reduce racial disparities in hypertension care and control: study protocol

BACKGROUND: Racial disparities in blood pressure control have been well documented in the United States. Research suggests that many factors contribute to this disparity, including barriers to care at patient, clinician, healthcare system, and community levels. To date, few interventions aimed at reducing hypertension disparities have addressed factors at all of these levels. This paper describes the design of Project ReD CHiP (Reducing Disparities and Controlling Hypertension in Primary Care), a multi-level system quality improvement project. By intervening on multiple levels, this project aims to reduce disparities in blood pressure control and improve guideline concordant hypertension care. METHODS: Using a pragmatic trial design, we are implementing three complementary multi-level interventions designed to improve blood pressure measurement, provide patient care management services and offer expanded provider education resources in six primary care clinics in Baltimore, Maryland. We are staggering the introduction of the interventions and will use Statistical Process Control (SPC) charting to determine if there are changes in outcomes at each clinic after implementation of each intervention. The main hypothesis is that each intervention will have an additive effect on improvements in guideline concordant care and reductions in hypertension disparities, but the combination of all three interventions will result in the greatest impact, followed by blood pressure measurement with care management support, blood pressure measurement with provider education, and blood pressure measurement only. This study also examines how organizational functioning and cultural competence affect the success of the interventions. DISCUSSION: As a quality improvement project, Project ReD CHiP employs a novel study design that specifically targets multi-level factors known to contribute to hypertension disparities. To facilitate its implementation and improve its sustainability, we have incorporated stakeholder input and tailored components of the interventions to meet the specific needs of the involved clinics and communities. Results from this study will provide knowledge about how integrated multi-level interventions can improve hypertension care and reduce disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT0156686

Dental care utilization during pregnancy by Medicaid dental coverage in 26 states: Pregnancy risk assessment monitoring system 2014–2015

Objective: To examine the association between Medicaid dental coverage for adult pregnant women with dental care utilization during pregnancy. Methods: Pregnancy risk assessment monitoring system (PRAMS) data (2014–2015) and the Medicaid-SCHIP state dental association (MSDA) national profiles (2014–2015) were used in this study. The study sample included 16,612 Medicaid-enrolled women, for a weighted number of 965,046 women from 26 states and New York City. State Medicaid dental coverage was categorized into (1) no coverage for the dental cleaning, (2) coverage for dental cleaning and fillings, (3) extended dental coverage. The adjusted prevalence ratios (aPR) for dental visits for cleaning during pregnancy were examined by Medicaid dental coverage level. Results: Medicaid-enrolled women in states with no dental coverage were less likely to visit dentists for cleaning during pregnancy (26.7%) compared with women in states with either limited dental coverage (36.6%) or extended dental coverage (44.9%). Compared with women in state without dental coverage, Medicaid-enrolled women in states with extended dental coverage (aPR = 1.20, 95% CI [1.16–1.23]) and women in states with limited coverage (aPR = 1.10, 95% CI [1.06–1.14]) were more likely to visit dentists for cleaning during pregnancy when adjusted for other sociodemographic variables and adequacy of prenatal care. A similar pattern of association was observed for a dental visit to address dental problems during pregnancy. Conclusions: This study highlights the importance of Medicaid dental coverage for adult pregnant women related to dental service utilization during pregnancy.N

Racial disparity in dental care during pregnancy: An analysis of the pregnancy risk assessment monitoring system from 2012 to 2015

Black women are less likely to visit dentists during pregnancy than White women when controlling for other socio-demographic variables. Using PRAMS data from 2012 to 2015, we examine the impact of perceived benefits of oral health and dental coverage on Black and White rates of utilizing dental care during pregnancy. Among 61,943 women of ages 20 and older with a recent history of birth in 31 states and New York City, Black women were significantly less likely to visit dentists for cleaning compared with White women. Compared with White women without dental coverage, Black women without dental coverage had more than 30% lower odds of visiting dentists. Analysis of the subpopulation of 1,737 women from five states that implemented additional oral health questions showed that Black women were significantly more likely to have difficulty in finding dentists than White women when controlling for other socio-demographic variables.N