Ann F. Chou

Social Support and Survival in Young Women with Breast Carcinoma

Purpose: Although previous evidence has shown increased likelihood for survival in cancer patients who have social support, little is known about changes in social support during illness and their impact on survival. This study examines the relationship between social support and survival among women diagnosed with breast carcinoma, specifically assessing the effect of network size and changes in social contact post‐diagnosis.

Physician attitude toward depression care interventions: Implications for implementation of quality improvement initiatives

BackgroundFew individuals with depression treated in the primary care setting receive care consistent with clinical treatment guidelines. Interventions based on the chronic care model (CCM) have been promoted to address barriers and improve the quality of care. A current understanding of barriers to depression care and an awareness of whether physicians believe interventions effectively address those barriers is needed to enhance the success of future implementation.MethodsWe conducted semi-structured interviews with 23 primary care physicians across the US regarding their experience treating patients with depression, barriers to care, and commonly promoted CCM-based interventions. Themes were identified from interview transcripts using a grounded theory approach.ResultsSix barriers emerged from the interviews: difficulty diagnosing depression, patient resistance, fragmented mental health system, insurance coverage, lack of expertise, and competing demands and other responsibilities as a primary care provider. A number of interventions were seen as helpful in addressing these barriers – including care managers, mental health integration, and education – while others received mixed reviews. Mental health consultation models received the least endorsement. Two systems-related barriers, the fragmented mental health system and insurance coverage limitations, appeared incompletely addressed by the interventions.ConclusionCCM-based interventions, which include care managers, mental health integration, and patient education, are most likely to be implemented successfully because they effectively address several important barriers to care and are endorsed by physicians. Practices considering the adoption of interventions that received less support should educate physicians about the benefit of the interventions and attend to physician concerns prior to implementation. A focus on interventions that address systems-related barriers is needed to overcome all barriers to care.

Measuring Practice Systems for Chronic Illness Care: Accuracy of Self-Reports from Clinical Personnel

BACKGROUND Purchasers, plans, and clinical practices involved in quality improvement initiatives are increasingly interested in measuring practice systems, particularly in relation to clinical quality and as part of pay-for-quality initiatives. The validity of self-reports of the use of practice systems was examined. METHODS In 11 medical groups in Minnesota, the Physician Practice Connections Readiness Survey, which was developed on the basis of the concepts and evidence base of the Chronic Care Model, was used to survey office practice personnel about practice systems. Participation rates by medical group ranged from 61% to 94%, with a mean of 76%, yielding surveys from 32 lead physicians and 241 other personnel. Survey results were compared with an on-site audit by trained surveyors. RESULTS Overall agreement with the on-site audit ranged from 40.9% to 96.7% among lead physicians and from 33.9% to 81.9% among other personnel. Mean agreement was high for quality improvement (96.7% for lead physicians and 81.9% for other personnel), moderate for clinical information systems (71.2% for lead physicians and 66.0% for others), and low for the use of care management (less than 50% for both groups). Mean positive predictive value ranged from 55.2% to 100% among lead physicians and from 49.6% to 100% among other personnel. Both the presence of systems and the accuracy of reporting varied across medical groups. DISCUSSION The accuracy of self-reports of practice systems varies by type of system being assessed and by type of respondent. Although self-assessment may be useful for quality improvement purposes, self-reported information on clinical practices systems should not be used for accountability purposes, including pay-for-quality efforts or public reporting unless additional documentation is required to ensure fair comparisons.

Implementation of evidence-based practices: Applying a goal commitment framework

Background: The implementation of evidence-based practices translates research findings into practice to reduce inappropriate care. However, this process is slow and unpredictable. The lack of a coherent theoretical basis for understanding individual and organizational behavior limits our ability to formulate effective implementation strategies. Purpose: The study objectives are (a) to test the goal commitment framework that explains mechanisms impacting outcomes of major depressive disorder (MDD) screening guideline implementation and (b) to understand the effects of implementation outcomes on provider practice related to MDD screening. Methods: Using data from the Determinants of Clinical Practice Guideline Implementation Effectiveness Study, the national sample included 2,438 clinicians from 139 Veteran Affairs acute care hospitals with primary care clinics. We used hierarchical generalized linear modeling to assess the following implementation outcomes: agreement with, adherence to, improvement in knowledge of guidelines, and delivery of best practices as a function of clinician input into implementation, teamwork, involvement in quality improvement activities, participative culture, interdepartmental coordination, frequency, and utility of performance feedback. We then estimated self-reported MDD screening practices as a function of these four implementation outcomes. Findings: Results showed that having input into implementation, involvement in quality of care improvement, teamwork, and perceived value of performance feedback were positively associated with implementation outcomes. Provider self-assessed guideline adherence was positively associated with the likelihood of appropriate MDD screening. Implications: Factors related to increased goal commitment positively predicted key implementation outcomes, which in turn enhanced care delivery. This study demonstrates that the goal commitment framework is useful in assisting managers to assess factors that facilitate implementation. In particular, participation, feedback, and team work equip organizational participants with better information about implementation targets, thereby increasing adherence. Instituting or improving systems or programs to facilitate timely, appropriate performance feedback and provider participation may help enhancing organizational change and learning.

Structural and process factors affecting the implementation of antimicrobial resistance prevention and control strategies in U.S. hospitals

Background: To address increases in the incidence of infection with antimicrobial-resistant pathogens, the National Foundation for Infectious Diseases and Centers for Disease Control and Prevention proposed two sets of strategies to (a) optimize antibiotic use and (b) prevent the spread of antimicrobial resistance and control transmission. However, little is known about the implementation of these strategies. Purpose: Our objective is to explore organizational structural and process factors that facilitate the implementation of National Foundation for Infectious Diseases/Centers for Disease Control and Prevention strategies in U.S. hospitals. Methods: We surveyed 448 infection control professionals from a national sample of hospitals. Clinically anchored in the Donabedian model that defines quality in terms of structural and process factors, with the structural domain further informed by a contingency approach, we modeled the degree to which National Foundation for Infectious Diseases and Centers for Disease Control and Prevention strategies were implemented as a function of formalization and standardization of protocols, centralization of decision-making hierarchy, information technology capabilities, culture, communication mechanisms, and interdepartmental coordination, controlling for hospital characteristics. Findings: Formalization, standardization, centralization, institutional culture, provider-management communication, and information technology use were associated with optimal antibiotic use and enhanced implementation of strategies that prevent and control antimicrobial resistance spread (all p < .001). However, interdepartmental coordination for patient care was inversely related with antibiotic use in contrast to antimicrobial resistance spread prevention and control (p < .0001). Implications: Formalization and standardization may eliminate staff role conflict, whereas centralized authority may minimize ambiguity. Culture and communication likely promote internal trust, whereas information technology use helps integrate and support these organizational processes. These findings suggest concrete strategies for evaluating current capabilities to implement effective practices and foster and sustain a culture of patient safety.

The interplay of contextual elements in implementation: an ethnographic case study

BackgroundContextual elements have significant impact on uptake of health care innovations. While existing conceptual frameworks in implementation science suggest contextual elements interact with each other, little research has described how this might look in practice. To bridge this gap, this study identifies the interconnected patterns among contextual elements that influence uptake of an anticoagulation clinic improvement initiative.MethodsWe completed 51 semi-structured interviews and ethnographic observations across five case study sites involved in an evidence-based practice (EBP) quality improvement initiative. We analyzed data in NVivo 10 using an a priori approach based on the Promoting Action on Research Implementation in Health Services (PARIHS) model and an emergent thematic analysis.ResultsKey contextual elements, such as leadership, teamwork, and communication, interacted with each other in contributing to site-level uptake of the EBP, often yielding results that could not be predicted by looking at just one of these elements alone. Sites with context conducive to change in these areas predictably had high uptake, while sites with uniformly weak contextual elements had low uptake. Most sites presented a mixed picture, with contextual elements being strongly supportive of change in some areas and weak or moderate in others. In some cases, we found that sites with strong context in at least one area only needed to have adequate context in other areas to yield high uptake. At other sites, weak context in just one area had the potential to contribute to low uptake, despite countervailing strengths. Even a site with positive views of EBPs could not succeed when context was weak.ConclusionInterrelationships among different contextual elements can act as barriers to uptake at some sites and as facilitators at others. Accounting for interconnections among elements enables PARIHS to more fully describe the determinants of successful implementation as they operate in real-world settings.

Quality assurance in medical and public health genetics services: A systematic review

As genetic services grow in scope, issues of quality assessment in genetic services are emerging. These efforts are well developed for molecular and cytogenetic testing and laboratories, and newborn screening programs, but assessing quality in clinical services has lagged, perhaps owing to the small work force and the recent evolution from a few large training programs to multiple training sites. We surveyed the English language, peer‐reviewed literature to summarize the knowledge‐base of quality assessment of genetics services, organized into the tripartite categories of the Donabedian model of “structure,” “process,” and “outcome.” MEDLINE searches from 1990 to July 2008, yielded 2,143 articles that addressed both “medical/genetic screening and counseling” and “quality indicators, control, and assurance.” Of the 2,143 titles, 131 articles were extracted for in‐depth analysis, and 55 were included in this review. Twenty‐nine articles focused on structure, 19 on process, and seven on outcomes. Our review underscored the urgent need for a coherent model that will provide health care organizations with tools to assess, report, monitor, and improve quality. The structure, process, and outcomes domains that make up the quality framework provide a comprehensive lens through which to examine quality in medical genetics.

Promoting Patient-Centered Preventive Care Using a Wellness Portal: Preliminary Findings

Optimal delivery of preventive services requires appropriate information processing and patient involvement. However, information is limited in preventive service delivery that integrates health information technology (HIT). This study aimed to develop and pilot test an Internet-based wellness portal to facilitate patient-centered care. Guiding portal development, an advisory panel systematically identified portal elements/features and engaged in the Delphi technique to achieve consensus on portal structure. To pilot test the portal, 30 patients were randomly recruited from 2 practices to complete a questionnaire. Frequency statistics were compiled for structured questions, and content analyses were conducted to examine qualitative responses on portal utility. Participant age ranged from 23 to 83 years (mean, 41 years). About 78% were female, 22% were ethnic minorities, and 80% had some college education. The portal provides a personalized wellness plan for preventive services based on patient demographics, medical history, risk factors, medications, laboratory tests, and functions like symptoms tracking, access to education materials, and secure patient-practice communication. Patients rated the portal in ease of use, importance, and utility/value. Over 90% found the portal easy to use in terms of navigation, finding information, comprehension, and instructions. Patients regarded the portal as an important tool in achieving wellness, improving patient-practice interactions, and a valuable resource. Contents analyses showed that patients found the portal helpful, particularly its reminder and tracking functions. Patients with basic computer literacy may use a simple, consumer-oriented Web site to manage their preventive care. The portal exemplifies how HIT may encourage active patient participation in their care and potentially improve health outcomes.

Dissemination of knowledge from randomized clinical trials for herpes simplex virus keratitis.

H erpes simplex virus type 1 (HSV), an enveloped virus with double-stranded DNA, is a major source of ocular infections. A 1982 study estimated that 400 000 people in the United States had ocular HSV infection, with 50 000 new and recurrent cases each year. Almost 20 years ago, the Herpetic Eye Disease Study Group was organized to elucidate the best treatments for HSV keratitis through the application of controlled, double-masked randomized clinical trials. The Herpetic Eye Disease Study trials demonstrated that topical corticosteroid with a prophylactic antiviral agent shortens the course of HSV stromal keratitis and that oral acyclovir prophylaxis significantly reduces recurrences. We surveyed eye care providers to examine the degree to which the best evidence-based practices (EBPs) in HSV keratitis have reached community care providers.

Organizational Factors Affecting the Likelihood of Cancer Screening Among VA Patients.

Background:Preventive service delivery, including cancer screenings, continues to pose a challenge to quality improvement efforts. Although many studies have focused on person-level characteristics associated with screening, less is known about organizational influences on cancer screening. Objectives:This study aims to understand the association between organizational factors and adherence to cancer screenings. Methods:This study employed a cross-sectional design using organizational-level, patient-level, and area-level data. Dependent variables included breast, cervical, and colorectal cancer screening. Organizational factors describing resource sufficiency were constructed using factor analyses from a survey of 250 Veterans Affairs primary care directors. We conducted random-effects logistic regression analyses, modeling cancer screening as a function of organizational factors, controlling for patient-level and area-level factors. Results:Overall, 87% of the patients received mammograms, 92% received cervical and 78% had colorectal screening. Quality improvement orientation increased the odds of cervical [odds ratio (OR): 1.27; 95% confidence interval (CI), 1.03–1.57] and colorectal cancer screening (OR: 1.10; 95% CI, 1.00–1.20). Authority in determining primary care components increased the odds of mammography screening (OR: 1.23; 95% CI, 1.03–1.51). Sufficiency in clinical staffing increased the odds of mammography and cervical cancer screenings. Several patient-level factors, serving as control variables, were associated with achievement of screenings. Conclusions:Resource sufficiency led to increased odds of screening possibly because they promote excellence in patient care by conveying organizational goals and facilitate goal achievement with resources. Complementary to patient-level factors, our findings identified organizational processes associated with better performance, which offer concrete strategies in which facilities can evaluate their capabilities to implement best practices to foster and sustain a culture of quality care.