Kimberly Ward

Facilitators of Transforming Primary Care: A Look Under the Hood at Practice Leadership

PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41–4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08–1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.

More extensive implementation of the chronic care model is associated with better lipid control in diabetes

Objective: Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes. Methods: We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL. Results: Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher “registry” and “protocol” KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant. Conclusions: Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.

The Antibiotic Prescribing Pathway for Presumed Urinary Tract Infections in Nursing Home Residents

Due to the high rates of inappropriate antibiotic prescribing for presumed urinary tract infections (UTIs) in nursing home (NH) residents, we sought to examine the antibiotic prescribing pathway and the extent to which it agrees with the Loeb criteria; findings can suggest strategies for antibiotic stewardship.

Health of Older Adults in Assisted Living and Implications for Preventive Care.

Purpose of the Study Older adults in residential care and assisted living (RC/AL) are less healthy than the general elderly population, and some have needs similar to those in nursing homes, making this an important group in which to assess potential overuse or underuse of preventive services. We determined the health status of RC/AL residents and distinguished characteristics between those who may and may not benefit from preventive services requiring a life expectancy ≥5 years. Design and Methods Cross-sectional survey of a nationally representative sample of RC/AL residents using 2010 data from the National Survey of Residential Care Facilities. The primary outcome was the weighted frequency distribution of health states using three predictive mortality indices: Charlson Comorbidity Index, 4-year mortality index, and 9-year mortality index. Results A total of 666,700 of 733,300 (weighted) residents met criteria for inclusion. Based on the three indices, 10%-15% were in good health, 11%-70% in intermediate health, and 20%-76% in poor health. Implications Using triangulation between 3 well-validated mortality indices, 10%-15% of RC/AL residents are in good health and highly likely to benefit from preventive services that require ≥5 year life expectancy. In addition, many residents have uncertain benefit and would benefit from shared decision making.

Nurse and Medical Provider Perspectives on Antibiotic Stewardship in Nursing Homes

To examine perspectives on antibiotic use and antibiotic stewardship of nurses and medical providers in nursing homes (NHs).

Urine culture testing in community nursing homes: Gateway to antibiotic overprescribing

OBJECTIVE To describe current practice around urine testing and identify factors leading to overtreatment of asymptomatic bacteriuria in community nursing homes (NHs) DESIGN Observational study of a stratified random sample of NH patients who had urine cultures ordered in NHs within a 1-month study period SETTING 31 NHs in North Carolina PARTICIPANTS 254 NH residents who had a urine culture ordered within the 1-month study period METHODS We conducted an NH record audit of clinical and laboratory information during the 2 days before and 7 days after a urine culture was ordered. We compared these results with the urine antibiogram from the 31 NHs. RESULTS Empirical treatment was started in 30% of cases. When cultures were reported, previously untreated cases received antibiotics 89% of the time for colony counts of ≥100,000 CFU/mL and in 35% of cases with colony counts of 10,000-99,000 CFU/mL. Due to the high rate of prescribing when culture results returned, 74% of these patients ultimately received a full course of antibiotics. Treated and untreated patients did not significantly differ in temperature, frequency of urinary signs and symptoms, or presence of Loeb criteria for antibiotic initiation. Factors most commonly associated with urine culture ordering were acute mental status changes (32%); change in the urine color, odor, or sediment (17%); and dysuria (15%). CONCLUSIONS Urine cultures play a significant role in antibiotic overprescribing. Antibiotic stewardship efforts in NHs should include reduction in culture ordering for factors not associated with infection-related morbidity as well as more scrutiny of patient condition when results become available. Infect Control Hosp Epidemiol 2017;38:524-531.

Older adults' preferences for colorectal cancer-screening test attributes and test choice.

Background Understanding which attributes of colorectal cancer (CRC) screening tests drive older adults’ test preferences and choices may help improve decision making surrounding CRC screening in older adults. Materials and methods To explore older adults’ preferences for CRC-screening test attributes and screening tests, we conducted a survey with a discrete choice experiment (DCE), a directly selected preferred attribute question, and an unlabeled screening test-choice question in 116 cognitively intact adults aged 70–90 years, without a history of CRC or inflammatory bowel disease. Each participant answered ten discrete choice questions presenting two hypothetical tests comprised of four attributes: testing procedure, mortality reduction, test frequency, and complications. DCE responses were used to estimate each participant’s most important attribute and to simulate their preferred test among three existing CRC-screening tests. For each individual, we compared the DCE-derived attributes to directly selected attributes, and the DCE-derived preferred test to a directly selected unlabeled test. Results Older adults do not overwhelmingly value any one CRC-screening test attribute or prefer one type of CRC-screening test over other tests. However, small absolute DCE-derived preferences for the testing procedure attribute and for sigmoidoscopy-equivalent screening tests were revealed. Neither general health, functional, nor cognitive health status were associated with either an individual’s most important attribute or most preferred test choice. The DCE-derived most important attribute was associated with each participant’s directly selected unlabeled test choice. Conclusion Older adults’ preferences for CRC-screening tests are not easily predicted. Medical providers should actively explore older adults’ preferences for CRC screening, so that they can order a screening test that is concordant with their patients’ values. Effective interventions are needed to support complex decision making surrounding CRC screening in older adults.

Pneumococcal Carriage and Vaccine Coverage in Retirement Community Residents.

To evaluate pneumococcal immunization in older adults living in retirement communities and to measure nasopharyngeal carriage of Streptococcus pneumoniae to better assess the potential for herd protection from the 13‐valent pneumococcal conjugate vaccine (PCV‐13) in these settings.

Costs and benefits of transforming primary care practices: a qualitative study of North Carolina's Improving Performance in Practice.

EXECUTIVE SUMMARY Primary care organizations must transform care delivery to realize the Institute for Healthcare Improvements Triple Aim of better healthcare, better health, and lower healthcare costs. However, few studies have considered the financial implications for primary care practices engaged in transformation. In this qualitative, comparative case study, we examine the practice‐level personnel and nonpersonnel costs and the benefits involved in transformational change among 12 primary care practices participating in North Carolinas Improving Performance in Practice (IPIP) program. We found average annual opportunity costs of

New or Worsening Symptoms and Signs in Community-Dwelling Persons with Dementia: Incidence and Relation to Use of Acute Medical Services

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