Do We Want to Know about patients’ perceptions of care? Insights from implementation science

The presentation will introduce the “We Want to Know” program, the goal of which is to make it easy for patients and family members who have concerns about care to express their concern and get a response. It will also describe how the program is being adopted and implemented across 10 hospitals in the Washington DC/Baltimore area, and will draw on key implementation science concepts to highlight the challenges in translating the program into practice. This presentation is part of the mini-symposium entitled Building Bridges to Cross the Quality Chasm : The Challenges of Engaging Clinicians in Patient-Centered Care

An investigation of the effects of conditioning on two ability estimates in DIF analyses when the data are two-dimensional.

Differential Item functioning is present when examinees of the same ability, but belonging to different groups, have differing probabilities of success on an item. Traditionally, DIF detection procedures have been implemented conditioning on total test score. However, if there are group differences on the abilities underlying test performance, and total score is used as the matching criterion, multidimensional item impact may be incorrectly identified as DIF. This study sought to confirm earlier research which demonstrated that multidimensional item impact may be identified as DIF, and then to determine whether conditioning on multiple ability estimates would improve item classification accuracy. Data were generated to simulate responses for 1000 reference group members and 1000 focal group members to two-dimensional tests. The focal group mean on the second ability was one standard deviation less than the reference group mean. The dimensional structure of the tests, the discrimination of the items, and the correlation between the two abilities were varied. Logistic regression and Mantel-Haenszel DIF analyses were conducted using total score as the matching criterion. As anticipated, substantial numbers of items were identified as DIF. Items were then selected into subtests based on item measurement direction. The logistic regression procedure was re-implemented, with subtest scores substituted for total score. In the majority of the conditions simulated, this change in criterion resulted in substantial reductions in Type I errors. The magnitude of the reductions were related to the dimensional structure of the test, and the discrimination of the items. Finally, DIF analyses of two real data sets were conducted, using the same procedures. For one of the two tests, substituting subtest scores for total score resulted in a reduction in number of items identified as DIF. These results suggest that multidimensionality in a data set may have a significant impact on the results of DIF analyses. If total score is used as the matching criterion very high Type I error rates may be expected under some conditions. By conditioning on subtest scores in lieu of total score in logistic regression analyses it may be possible to substantially reduce the number of Type I errors, at least in some circumstances

Using Home Visits to Understand Medication Errors in Children

Summary: Current research methods are not well designed to detect medication errors that occur at home. We developed home visit methods to investigate home medication errors in children with chronic conditions. These methods include observation of parent administration of medication to the child by a trained nurse observer who takes detailed ethnographic notes; review of all prescription and over-the-counter medications for dispensing errors, pill counts, and medication reconciliation; and parent interviews to identify barriers to effective home use of medications, prior home medication errors that parents are aware of, and suggestions for systemic improvements. Details about each possible error detected are recorded using a structured data collection form (allergies, medication list, dispensing errors, administration errors). We conducted several pilot home visits and found that this approach has the potential to help understand home medication errors in order to develop interventions to improve the safety of medication self-management

A vision for using online portals for surveillance of patient-centered communication in cancer care

The Veterans Health Administration (VHA) is charged with providing high-quality health care, not only in terms of technical competence but also with regard to patient-centered care experiences. Patient-centered coordination of care and communication are especially important in cancer care, as deficiencies in these areas have been implicated in many cases of delayed cancer diagnosis and treatment. Additionally, because cancer care facilities are concentrated within the VHA system, geographical and system-level barriers may present prominent obstacles to quality care. Systematic assessment of patient-centered communication (PCC) may help identify both individual veterans who are at risk of suboptimal care and opportunities for quality improvement initiatives at the service, facility, or system-wide level. In this manuscript, we describe our vision to implement an assessment of PCC through patient self-report to improve the quality of cancer care and other health services in the VHA. We outline a possible strategy to assess PCC that leverages the VHA’s existing initiative to promote use of an online personal health record for veterans (MyHealtheVet). Questionnaires administered periodically or following specific episodes of care can be targeted to assess PCC in cancer care. Assessment of PCC can also be tied to clinical and administrative data for more robust analysis of patient outcomes. Ultimately, the goal of any assessment of PCC is to gather valid, actionable data that can assist VHA clinicians and staff with providing the best possible care for veterans with cancer

ComprehENotes, an Instrument to Assess Patient Reading Comprehension of Electronic Health Record Notes: Development and Validation

BACKGROUND: Patient portals are widely adopted in the United States and allow millions of patients access to their electronic health records (EHRs), including their EHR clinical notes. A patient\u27s ability to understand the information in the EHR is dependent on their overall health literacy. Although many tests of health literacy exist, none specifically focuses on EHR note comprehension. OBJECTIVE: The aim of this paper was to develop an instrument to assess patients\u27 EHR note comprehension. METHODS: We identified 6 common diseases or conditions (heart failure, diabetes, cancer, hypertension, chronic obstructive pulmonary disease, and liver failure) and selected 5 representative EHR notes for each disease or condition. One note that did not contain natural language text was removed. Questions were generated from these notes using Sentence Verification Technique and were analyzed using item response theory (IRT) to identify a set of questions that represent a good test of ability for EHR note comprehension. RESULTS: Using Sentence Verification Technique, 154 questions were generated from the 29 EHR notes initially obtained. Of these, 83 were manually selected for inclusion in the Amazon Mechanical Turk crowdsourcing tasks and 55 were ultimately retained following IRT analysis. A follow-up validation with a second Amazon Mechanical Turk task and IRT analysis confirmed that the 55 questions test a latent ability dimension for EHR note comprehension. A short test of 14 items was created along with the 55-item test. CONCLUSIONS: We developed ComprehENotes, an instrument for assessing EHR note comprehension from existing EHR notes, gathered responses using crowdsourcing, and used IRT to analyze those responses, thus resulting in a set of questions to measure EHR note comprehension. Crowdsourced responses from Amazon Mechanical Turk can be used to estimate item parameters and select a subset of items for inclusion in the test set using IRT. The final set of questions is the first test of EHR note comprehension

Barriers and Facilitators to Genetic Testing for Familial Hypercholesterolemia in the United States: A Review

Familial Hypercholesterolemia (FH) is an underdiagnosed condition in the United States (US) and globally, affecting an estimated 1/250 individuals. It is a genetic risk factor for premature cardiovascular disease and is responsible for an estimated 600,000 to 1.2 million preventable vascular events. Studies show that FH genetic testing can identify a causal gene variant in 60 to 80% of clinically suspected FH cases. However, FH genetic testing is currently underutilized in clinical settings in the US despite clinical recommendations and evidence supporting its use. Reasons for underutilization are not well understood. We conducted a literature review in the PubMed/MEDLINE database and eight peer-reviewed journals. After filtering for and reviewing 2340 articles against our inclusion criteria, we included nine commentaries or expert opinions and eight empirical studies reported between January 2014 and March 2019 in our review. After applying the Consolidated Framework for Implementation Research (CFIR), we identified a total of 26 potential barriers and 15 potential facilitators (estimated barrier to facilitator ratio of 1.73). We further estimated ratios of potential barriers to facilitators for each CFIR domain (Characteristics of Intervention, Outer Setting, Inner Setting, Characteristics of Individuals, and Process). Findings derived from our systematic approach to the literature and calculations of estimated baseline ratios of barriers and facilitators can guide future research to understand FH genetic testing implementation in diverse clinical settings. Our systematic approach to the CFIR could also be used as a model to understand or compare barriers and facilitators to other evidence-based genetic testing processes in health care settings in the US and abroad

The dependability of students\u27 ratings of preceptors

No abstract provided

Validation of a new measure of concept of a good death

BACKGROUND: The concept of a good death is central to end-of-life care research. Despite its importance and the high interest in the topic, there are few measures currently available for use in clinical research. PURPOSE: The present work describes the development and testing of a set of items intended to measure the importance of several components posited to be critical to the concept of a good death. It is intended for use with health care providers and lay people in the context of end-of-life care research and education. POPULATION: Four cohorts (n = 596) were recruited to participate, representing two helping profession disciplines, nonhelping professionals, and a range of ages, specifically: (1) undergraduate medical students; (2) master\u27s degree students in nursing; (3) graduate students from the life sciences; and (4) practicing hospice nurses. METHODS: Participants completed self-report questionnaires at baseline and retest. Psychometric analyses included item frequency distributions, factor analysis, alpha reliability, intraclass correlation, and measures of association. RESULTS: The new Concept of a Good Death measure demonstrated good item frequency distributions, acceptable internal consistency reliability, and test-retest stability. Its factor structure revealed that three distinct domains are measured, reflecting the psychosocial/spiritual, physical, and clinical aspects of a good death. An examination of patterns of correlations showed differential associations with death anxiety, spiritual beliefs and practices, anxious mood, and sociodemographic characteristics. CONCLUSIONS: The new Concept of a Good Death instrument appears to measure three distinct factors which people consider important to a Good Death. Ratings of the importance of these factors are reliable and valid. The instrument has the advantage of being a brief, self-report index for use in end-of-life care research

Gout Knowledge, Beliefs and Treatment Practices in a National Sample of US Primary Care Providers

Objectives: We sought to examine primary care providers’ gout knowledge and reported treatment patterns in comparison to current treatment recommendations. Methods: We conducted a national survey of a random sample of primary care physicians (internists and family practitioners) to assess their treatment of acute, intercritical, and tophaceous gout in comparison to published European and American gout treatment recommendations and guidelines. Results: There were 838 respondents (response rate of 41%) most of whom worked in private practice (63%) with \u3e16 years experience (52%). For acute podagra, 16% reported care consistent with the recommendations including avoidance of anti-inflammatory drugs in the setting of renal insufficiency, use of colchicine at a dose of ≤ 1.8mg a day, and no initiation of a urate-lowering drug (ULD) during an acute attack (internists 21% vs. family practitioners 11%, p Conclusion: While internists were more likely than family practitioners to suggest recommended care, the majority of physicians did not report optimal treatment practices, suggesting further education is needed