Jeffrey L. Solomon

Barriers and facilitators to routine HIV testing in VA primary care.

ABSTRACTBACKGROUNDApproximately 21% of the 1.1 million HIV-infected persons in the United States are unaware of their HIV status. The Centers for Disease Control (CDC) recommend routine opt-out HIV testing for all patients aged 13–64. Yet little is known about patient and provider perspectives on routine HIV testing.OBJECTIVEWe sought to understand patient and provider perspectives on the adoption of routine HIV testing within the US Department of Veterans Affairs.DESIGNWe conducted four focus groups with patients and two focus groups with primary care providers to explore perceptions of, communication about, and barriers and facilitators to routine HIV testing in primary care.PARTICIPANTSConvenience sample of patients and primary care providers at two geographically diverse Veterans’ Affairs Medical Centers.APPROACHWe conducted grounded thematic analyses of transcribed audio-recordings of focus groups to identify major themes, identifying similarities and differences between patient and provider perspectives.MAIN RESULTSPatients and providers concurred that implementation of routine HIV testing, treating HIV like other chronic diseases, and removing requirements for written informed consent and pre-test counseling were of benefit to patients and to public health. Patients, however, wished to have HIV testing routinely offered by providers so that they could decide whether or not to be tested. Veterans also stated that routinizing testing would help destigmatize HIV. Six steps to communicating about routine testing (“the 6 R’s”) were identified.CONCLUSIONSPatients and providers appear ready for implementation of routine HIV testing. However, providers should use patient-centered communication strategies to ease patients’ concerns about confidentiality and stigma associated with HIV disease.

The Role of Patients’ Explanatory Models and Daily-Lived Experience in Hypertension Self-Management

ABSTRACTBACKGROUNDUncontrolled hypertension remains a significant problem for many patients. Few interventions to improve patients’ hypertension self-management have had lasting effects. Previous work has focused largely on patients’ beliefs as predictors of behavior, but little is understood about beliefs as they are embedded in patients’ social contexts.OBJECTIVEThis study aims to explore how patients’ “explanatory models” of hypertension (understandings of the causes, mechanisms or pathophysiology, course of illness, symptoms and effects of treatment) and social context relate to their reported daily hypertension self-management behaviors.DESIGNSemi-structured qualitative interviews with a diverse group of patients at two large urban Veterans Administration Medical centers.PARTICIPANTS (OR PATIENTS OR SUBJECTS)African-American, white and Latino Veterans Affairs (VA) primary care patients with uncontrolled blood pressure.APPROACHWe conducted thematic analysis using tools of grounded theory to identify key themes surrounding patients’ explanatory models, social context and hypertension management behaviors.RESULTSPatients’ perceptions of the cause and course of hypertension, experiences of hypertension symptoms, and beliefs about the effectiveness of treatment were related to different hypertension self-management behaviors. Moreover, patients’ daily-lived experiences, such as an isolated lifestyle, serious competing health problems, a lack of habits and routines, barriers to exercise and prioritizing lifestyle choices, also interfered with optimal hypertension self-management.CONCLUSIONSDesigning interventions to improve patients’ hypertension self-management requires consideration of patients’ explanatory models and their daily-lived experience. We propose a new conceptual model — the dynamic model of hypertension self-management behavior — which incorporates these key elements of patients’ experiences.

Development and Evaluation of an Internet and Personal Health Record Training Program for Low-income Patients With HIV or Hepatitis C

Background: Vulnerable populations face difficulties accessing and using the internet and personal health record (PHR) systems for health-related purposes. Populations disconnected from the internet also tend to be disconnected from health care services. Objectives: To develop and evaluate an intervention to increase skills in health-related internet and PHR use for vulnerable populations with limited computer and internet experience. Research Design: Preevaluation and postevaluation using quantitative surveys, semistructured interviews, focus groups, and ethnographic observation. Subjects: Fourteen low-income Veterans receiving care at Veterans Affairs medical centers for human immunodeficiency virus or hepatitis C. Measures: Internet and PHR use, self-efficacy, patient activation, disease knowledge, predictors of medication adherence. Results: At follow-up one (FU1), mean number of internet for health features used increased from 1.57 to 4.07 (P<0.001) as did number of PHR features, from 0.36 to 2.00 (P<0.001). Mean self-efficacy increased at FU1, from 7.12 to 8.60, (P=0.009) and was maintained at follow-up two (FU2). Patient activation increased only at FU2, from 3.42 to 3.61 (P=0.03). Disease specific knowledge showed borderline increase at FU1, from 67.9% to 72.2% (P=0.05), whereas there were no changes in predictors of medication adherence. Qualitative findings underscored the interest in using internet and PHRs and their contribution to increased engagement in care. Training cost per participant was

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans

287. Conclusions: Group training of vulnerable patients represents a cost-effective method to increase internet and PHR skills, and improve patient confidence in finding health-related information, making online health-related transactions, and interacting with health care providers.

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

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans’ IT use. This study examines homeless veterans’ access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

Implementation of Nurse-Initiated Rapid HIV Testing at High-Prevalence Primary Care Sites Within the US Veterans Affairs Health Care System

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.

Examining the validity of AHRQ's patient safety indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.

Balancing Collaborative and Independent Practice Roles in Clinical Pharmacy A Qualitative Research Study

Increasing use of Agency for Healthcare Research and Quality’s Patient Safety Indicators (PSIs) for hospital performance measurement intensifies the need to critically assess their validity. Our study examined the extent to which variation in PSI composite score is related to differences in hospital organizational structures or processes (i.e., criterion validity). In site visits to three Veterans Health Administration hospitals with high and three with low PSI composite scores (“low performers” and “high performers,” respectively), we interviewed a cross-section of hospital staff. We then coded interview transcripts for evidence in 13 safety-related domains and assessed variation across high and low performers. Evidence of leadership and coordination of work/communication (organizational process domains) was predominantly favorable for high performers only. Evidence in the other domains was either mixed, or there were insufficient data to rate the domains. While we found some evidence of criterion validity, the extent to which variation in PSI rates is related to differences in hospitals’ organizational structures/processes needs further study.

The role of comorbidities in patients’ hypertension self-management

Background: Clinical pharmacists (CPs) with a scope of practice operate as direct care providers and health care team members. Research often focuses on one role or the other; little is understood about the dynamic relationship between roles in practice settings. Objective: To identify the challenges CPs face in balancing dual roles as direct care providers and health care team members and the implications for CP effectiveness and quality of care. Methods: Pharmacists were interviewed with a primary purpose of informing an implementation effort. Besides the implementation, there were emergent themes regarding the challenges posed for CPs in negotiating dual roles. This study is, therefore, a secondary analysis of semistructured interviews and direct observation of 48 CPs, addressing this phenomenon. Interview data were entered into NVivo 10 and systematically analyzed using an emergent thematic coding strategy. Results: Pharmacists describe role ambiguity, where they perform as direct providers or team members simultaneously or in quick succession. They note the existence of a “transaction cost,” where switching causes loss of momentum or disruption of work flow. Additionally, pharmacists feel that fellow providers lack an understanding of what they do and that CP contributions are not evaluated accurately by other health professionals. Conclusion: It is a challenge for CPs to balance the distinct roles of serving as collaborators and primary providers. Frequent role switching is not conducive to optimal work efficiency or patient care. Our findings suggest concrete steps that medical centers can take to improve both CP worklife and quality of patient care.

Contextual Facilitators of and Barriers to Nursing Home Pressure Ulcer Prevention.

Objective We sought to understand barriers to hypertension self-management in patients with hypertension and comorbidities. Methods We conducted semi-structured, qualitative interviews with 48 patients with uncontrolled hypertension and at least one comorbidity to learn about beliefs and behaviors that might affect hypertension self-management. Using a grounded theory strategy, we analyzed interview transcripts detailing patients’ hypertension self-management behaviors vis-à-vis a framework including Explanatory Models—a patient’s understanding of the pathophysiology, cause, course, treatment, and severity of an illness, such as hypertension. Results We identified four factors that interfered with hypertension self-management. (1) Interdependence: Participants saw hypertension as interconnected to their comorbidities and subsequently had difficulty separating information about their illnesses. (2) Low priority: Compared to other conditions, participants assigned hypertension a lower priority. (3) Conflicts: Participants struggled with conflicts between hypertension self-management practices and those for comorbidities. (4) Managing multiple medications: Polypharmacy led to patients’ confusion and concern about taking medications as prescribed. Discussion Participants did not experience hypertension as a discreet clinical condition; rather, they self-managed hypertension concurrently with other conditions, leading to a breakdown in hypertension self-management. We provide strategies to address each of the four barriers to better equip providers in addressing their clinically salient concerns.