Thomas Ludden

Using Geographic Information Systems (GIS) to Understand a Community's Primary Care Needs

Introduction: A key element for reducing health care costs and improving community health is increased access to primary care and preventative health services. Geographic information systems (GIS) have the potential to assess patterns of health care utilization and community-level attributes to identify geographic regions most in need of primary care access. Methods: GIS, analytical hierarchy process, and multiattribute assessment and evaluation techniques were used to examine attributes describing primary care need and identify areas that would benefit from increased access to primary care services. Attributes were identified by a collaborative partnership working within a practice-based research network using tenets of community-based participatory research. Maps were created based on socioeconomic status, population density, insurance status, and emergency department and primary care safety-net utilization. Results: Individual and composite maps identified areas in our community with the greatest need for increased access to primary care services. Conclusions: Applying GIS to commonly available community- and patient-level data can rapidly identify areas most in need of increased access to primary care services. We have termed this a Multiple Attribute Primary Care Targeting Strategy. This model can be used to plan health services delivery as well as to target and evaluate interventions designed to improve health care access.

Trajectories of Multidimensional Neighbourhood Quality of Life Change

This paper provides an empirical analysis of the multidimensional, spatio-temporal quality of life (QoL) trends followed by neighbourhoods in Charlotte, NC, between 2000 and 2010. Employing a combined geocomputational and visual technique based on the self-organising map, the study addresses which types of neighbourhood experienced the most change or stability, where (in attribute and geographical spaces) did neighbourhoods that began the decade with a particular set of characteristics evolve to, and where did neighbourhoods that concluded the decade transition from? Results indicate that the highest QoL neighbourhoods were most stable, while those with lower homeownership, closer to the city centre, exhibited the sharpest longitudinal trajectories. Lower-income neighbourhoods are found to be heterogeneous in terms of their social problems, dividing between high crime concentrations and youth-related social problems. An exchange of these social issues over time is observed as well as a geographical spread of crime to middle-ring suburbs.

Geographic Information Systems (GIS) Demonstrating Primary Care Needs for a Transitioning Hispanic Community

Background: Hispanics are the largest and fastest growing minority group in the United States. Charlotte, NC, had the 4th fastest growing Hispanic community in the nation between 1990 to 2000. Gaining understanding of the patterns of health care use for this changing population is a key step toward designing improved primary care access and community health. Methods: The Multiple Attribute Primary Care Targeting Strategy process was applied to key patient- and community-level attributes describing the Charlotte Hispanic community. Maps were created based on socioeconomic status, population density, insurance status, and use of the emergency department as a primary care safety net. Each of these variables was weighed and added to create a single composite map. Results: Individual attribute maps and the composite map identified geographic locations where Hispanic community members would most benefit from increased access to primary care services. Conclusions: Using the Multiple Attribute Primary Care Targeting Strategy process we were able to identify geographic areas within our community where many Hispanic immigrants face barriers to accessing appropriate primary care services. These areas can subsequently be targeted for interventions that improve access to primary care and reduce emergency department use. The geospatial model created through this process can be monitored over time to determine the effectiveness of these interventions.

Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma

ABSTRACT Objective: Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. Methods: Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. Results: The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. Conclusions: The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.

Evaluating primary care delivery systems for an uninsured Hispanic immigrant population.

Hispanic populations experience disparities in health outcomes and health care. Using participatory methods, we evaluated 4 systems of primary care delivery for an uninsured Hispanic population. Best practices were determined that could be translated back to the partner clinics and the community. The assessment included patient service areas, provider discussion groups, patient surveys, calculation of travel distances, and costs. The following best practices were identified: improved proximity to services, enhanced bilingual services, affordable services, and integrated services. Researchers and providers not only identified translatable service delivery practices but also laid the foundation for ongoing research partnerships.

A Multidisciplinary Intervention Utilizing Virtual Communication Tools to Reduce Health Disparities: A Pilot Randomized Controlled Trial

Advances in technology are likely to provide new approaches to address healthcare disparities for high-risk populations. This study explores the feasibility of a new approach to health disparities research using a multidisciplinary intervention and advanced communication technology to improve patient access to care and chronic disease management. A high-risk cohort of uninsured, poorly-controlled diabetic patients was identified then randomized pre-consent with stratification by geographic region to receive either the intervention or usual care. Prior to enrollment, participants were screened for readiness to make a behavioral change. The primary outcome was the feasibility of protocol implementation, and secondary outcomes included the use of patient-centered medical home (PCMH) services and markers of chronic disease control. The intervention included a standardized needs assessment, individualized care plan, intensive management by a multidisciplinary team, including health coach-facilitated virtual visits, and the use of a cloud-based glucose monitoring system. One-hundred twenty-seven high-risk, potentially eligible participants were randomized. Sixty-one met eligibility criteria after an in-depth review. Due to limited resources and time for the pilot, we only attempted to contact 36 participants. Of these, we successfully reached 20 (32%) by phone and conducted a readiness to change screen. Ten participants screened in as ready to change and were enrolled, while the remaining 10 were not ready to change. Eight enrolled participants completed the final three-month follow-up. Intervention feasibility was demonstrated through successful implementation of 13 out of 14 health coach-facilitated virtual visits, and 100% of participants indicated that they would recommend the intervention to a friend. Protocol feasibility was demonstrated as eight of 10 participants completed the entire study protocol. At the end of the three-month intervention, participants had a median of nine total documented contacts with PCMH providers compared to four in the control group. Three intervention and two control participants had controlled diabetes (hemoglobin A1C <9%). Multidisciplinary care that utilizes health coach-facilitated virtual visits is an intervention that could increase access to intensive primary care services in a vulnerable population. The methods tested are feasible and should be tested in a pragmatic randomized controlled trial to evaluate the impact on patient-relevant outcomes across multiple chronic diseases.

Asthma dissemination around patient-centered treatments in North Carolina (ADAPT-NC): a cluster randomized control trial evaluating dissemination of an evidence-based shared decision-making intervention for asthma management

Abstract Objective: To compare three dissemination approaches for implementing an asthma shared decision-making (SDM) intervention into primary care practices. Methods: We randomized thirty practices into three study arms: (1) a facilitator-led approach to implementing SDM; (2) a one-hour lunch-and-learn training on SDM; and (3) a control group with no active intervention. Patient perceptions of SDM were assessed in the active intervention arms using a one-question anonymous survey. Logistic regression models compared the frequency of asthma exacerbations (emergency department (ED) visits, hospitalizations, and oral steroid prescriptions) between the three arms. Results: We collected 705 surveys from facilitator-led sites and 523 from lunch-and-learn sites. Patients were more likely to report that they participated equally with the provider in making the treatment decision in the facilitator-led sites (75% vs. 66%, p = 0.001). Comparisons of outcomes for patients in the facilitator-led (n = 1,658) and lunch-and-learn (n = 2,613) arms respectively vs. control (n = 2,273) showed no significant differences for ED visits (Odds Ratio [OR] [95%CI] = 0.77[0.57–1.04]; 0.83[0.66–1.07]), hospitalizations (OR [95%CI] = 1.30[0.59–2.89]; 1.40 [0.68–3.06]), or oral steroids (OR [95%CI] =0.95[0.79–1.15]; 1.03[0.81–1.06]). Conclusion: Facilitator-led dissemination was associated with a significantly higher proportion of patients sharing equally in decision-making with the provider compared to a traditional lunch-and-learn approach. While there was no significant difference in health outcomes between the three arms, the results were most likely confounded by a concurrent statewide asthma initiative and the pragmatic implementation of the intervention. These results offer support for the use of structured approaches such as facilitator-led dissemination of complex interventions into primary care practices.

Patient and provider perspectives on uptake of a shared decision making intervention for asthma in primary care practices

ABSTRACT Objective: Poor outcomes and health disparities related to asthma result in part from difficulty disseminating new evidence such as shared decision making (SDM) into clinical practice. As part of a three-arm cluster randomized dissemination study, evaluation of the impact of different dissemination methods was studied. Here we evaluate themes from patient and provider focus groups to assess the impact of a facilitated, traditional dissemination approach, or no intervention, on patient and provider perspectives of asthma care. Methods: Using semi-structured questions, twenty-four pre- and post-intervention focus groups with patients and providers took place across primary care practices. Discussions were held in all three arms both before and after the time of intervention rollout. Audio recordings were transcribed and analyzed for themes. Results: Across all sites patients and providers discussed themes of communication, asthma self-management, barriers, education, and patient awareness. After the intervention, compared to traditional sites, facilitated practices were more likely to discuss themes related to SDM, such as patient-centered communication, patient-provider negotiation on treatment plan, planning, goal-setting, and solutions to barriers. Conclusions: Emergent themes allowed for further understanding of how the SDM implementation was perceived at the patient and provider level. The facilitated implementation was associated with higher adoption of the SDM intervention. These themes and supporting quotes add to knowledge of best practices associated with implementing an evidence-based SDM intervention for asthma into primary care and will inform researchers, practices, and providers as they work to improve adoption of evidence-based interventions into practice.

Racial/ethnic differences in healthcare use among patients with uncontrolled and controlled diabetes

ABSTRACT Objectives: To examine racial/ethnic differences in healthcare use among patients classified as having controlled and uncontrolled diabetes. Design: Data from the Carolinas HealthCare System electronic data warehouse were used. Glycemic control was defined as glycosylated hemoglobin (HbA1c) < 8% (64 mmol/mol) in 2012 (n = 9996). Patients with HbA1c ≥ 8% (64 mmol/mol) in 2012 were classified as uncontrolled (n = 2576). Race and ethnicity were jointly classified as non-Hispanic Black, non-Hispanic White or Other. Separate mixed effects negative binomial models estimated the independent effect of race/ethnicity on the number of emergency department (ED) visits, hospitalizations and physician office visits in 2013, in each patient group, adjusting for significant confounding variables. Results: Rates of diabetes-related ED visits were two to three times higher for non-Hispanic Blacks compared to non-Hispanic Whites (uncontrolled rate ratio [RR]: 3.41 95% CI: 1.41–8.22; controlled RR: 2.95; 95% CI: 1.78–4.91). Similar differences were observed for all-cause ED visits (uncontrolled RR: 1.83, 95% CI: 1.50–2.24; controlled RR: 2.45, 95% CI: 2.17–2.77). Non-Hispanic Blacks with controlled and uncontrolled diabetes also had lower rates of all-cause physician office visits when compared to non-Hispanic Whites (uncontrolled RR: 0.84, 95% CI: 0.77–0.91; controlled RR: 0.81, 95% CI: 0.78–0.84). Conclusion: Notable racial/ethnic disparities exist in the use of emergency services and physician offices for diabetes care. Strategies such as patient education and care delivery changes that address healthcare access issues in racial/ethnic minorities should be considered to offer better diabetes management and address diabetes disparities.