Zsolt Nagykaldi

Implementation of Evidence-Based Preventive Services Delivery Processes in Primary Care: An Oklahoma Physicians Resource/Research Network (OKPRN) Study

Background: Previous research has found that wellness visits, recall and reminder systems, and standing orders are associated with higher rates of delivery of preventive services in primary care practices. However, there is little information about how to help practices implement these processes. Methods: A 6-month randomized, controlled trial comparing a multicomponent quality improvement intervention to feedback and benchmarking. One clinician/nurse team from each of 24 practices was randomly assigned to one of 2 study arms. Intervention practices received performance feedback, peer-to-peer education (academic detailing), a practice facilitator, and computer (information technology) support. Implementation of the 3 targeted processes was determined by a blinded 3-clinician panel that reviewed transcribed clinician interviews before and after intervention using performance definitions. Rates of delivery of selected preventive services were determined by chart audit. Results: Intervention practices implemented more of the processes than control practices overall (P = .003), for adults (P = .05), and for children (P = .04). They were also more likely to implement at least one of the processes for children (P = .04) and to implement standing orders for either children or adults (P = .02). Mammography rates increased significantly. Neither clinician and practice characteristics nor clinician readiness to change predicted implementation. Conclusions: A multicomponent implementation strategy consisting of feedback, benchmarking, academic detailing, facilitation, and IT support increased implementation of evidence-based processes for delivering preventive services to a greater extent than performance feedback and benchmarking alone.

Usability Evaluation of an Online, Tailored Self-Management Intervention for Chronic Obstructive Pulmonary Disease Patients Incorporating Behavior Change Techniques

Background An eHealth intervention using computer tailored technology including several behavior change techniques was developed to support the self-management of chronic obstructive pulmonary disease patients. Objective The goal of this study was to evaluate and improve the usability of the eHealth intervention. Methods We conducted a usability evaluation with 8 chronic obstructive pulmonary disease patients, with a mixed methods design. We improved the usability through iterative cycles of evaluation and adaptation. Participants were asked to think aloud during the evaluation sessions. Participants then completed a semi-structured interview. The sessions were observed and recorded. Descriptive statistics and content analysis were used to uncover usability issues. Results Areas for improvement were layout, navigation, and content. Most issues could be solved within 3 iterations of improvement. Overall, participants found the program easy to use. The length of the program urged us to further analyze the appreciation of behavior change techniques. Some were perceived as helpful and easy to use, while others evoked frustration. Conclusions The usability study identified several issues for improvement, confirming the need for usability evaluation during the development of eHealth interventions. The uncovered strengths and limitations of behavior change techniques may lead to optimization of eHealth interventions, but further insight is needed.

The role of health information technology in the translation of research into practice: An Oklahoma Physicians Resource/Research Network (OKPRN) study

Implementation of health information technology (HIT) has become a cornerstone of efforts to improve patient care in primary care practices. However, relatively few publications have explored the impact of HIT on the need for fundamental changes in the primary care delivery process. There is also very little published information about how HIT implementations can drive translation of research findings into practice in primary care. This article describes the process of developing and implementing the Preventive Services Reminder System in the Oklahoma Physicians Resource/Research Network, a practice-based research network, and demonstrates how strategic adoption of HIT led to the re-engineering of practices and to subsequent improvements in delivery of evidence-based preventive services.

Integrating a tailored e-health self-management application for chronic obstructive pulmonary disease patients into primary care: a pilot study

BackgroundChanges in reimbursement have been compelling for Dutch primary care practices to apply a disease management approach for patients with chronic obstructive pulmonary disease (COPD). This approach includes individual patient consultations with a practice nurse, who coaches patients in COPD management. The aim of this study was to gauge the feasibility of adding a web-based patient self-management support application, by assessing patients’ self-management, patients’ health status, the impact on the organization of care, and the level of application use and appreciation.MethodsThe study employed a mixed methods design. Six practice nurses recruited COPD patients during a consultation. The e-Health application included a questionnaire that captured information on demographics, self-management related behaviors (smoking cessation, physical activity and medication adherence) and their determinants, and nurse recommendations. The application provided tailored feedback messages to patients and provided the nurse with reports. Data were collected through questionnaires and medical record abstractions at baseline and one year later. Semi-structured interviews with patients and nurses were conducted. Descriptive statistics were calculated for quantitative data and content analysis was used to analyze the qualitative data.ResultsEleven patients, recruited by three nurses, used the application 1 to 7 times (median 4). Most patients thought that the application supported self-management, but their interest diminished after multiple uses. Impact on patients’ health could not be determined due to the small sample size. Nurses reported benefits for the organization of care and made suggestions to optimize the use of the reports.ConclusionResults suggest that it is possible to integrate a web-based COPD self-management application into the current primary care disease management process. The pilot study also revealed opportunities to improve the application and reports, in order to increase technology use and appreciation.

A randomised controlled trial testing a web-based, computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease: a study protocol

BackgroundChronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality. Effective self-management support interventions are needed to improve the health and functional status of people with COPD or at risk for COPD. Computer-tailored technology could be an effective way to provide this support.Methods/DesignThis paper presents the protocol of a randomised controlled trial testing the effectiveness of a web-based, computer-tailored self-management intervention to change health behaviours of people with or at risk for COPD. An intervention group will be compared to a usual care control group, in which the intervention group will receive a web-based, computer-tailored self-management intervention. Participants will be recruited from an online panel and through general practices. Outcomes will be measured at baseline and at 6 months. The primary outcomes will be smoking behaviour, measuring the 7-day point prevalence abstinence and physical activity, measured in minutes. Secondary outcomes will include dyspnoea score, quality of life, stages of change, intention to change behaviour and alternative smoking behaviour measures, including current smoking behaviour, 24-hour point prevalence abstinence, prolonged abstinence, continued abstinence and number of quit attempts.DiscussionTo the best of our knowledge, this will be the first randomised controlled trial to test the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD. The results will be important to explore the possible benefits of computer-tailored interventions for the self-management of people with or at risk for COPD and potentially other chronic health conditions.Dutch trial registerNTR3421

Pet Dogs and Children’s Health: Opportunities for Chronic Disease Prevention?

Introduction Positive associations between having a pet dog and adult health outcomes have been documented; however, little evidence exists regarding the benefits of pet dogs for young children. This study investigates the hypothesis that pet dogs are positively associated with healthy weight and mental health among children. Methods This cross-sectional study accrued a consecutive sample of children over 18 months in a pediatric primary care setting. The study enrolled 643 children (mean age, 6.7 years); 96% were white, 45% were female, 56% were privately insured, and 58% had pet dogs in the home. Before an annual visit, parents of children aged 4 to 10 years completed the DartScreen, a comprehensive Web-based health risk screener administered using an electronic tablet. The screener domains were child body mass index (BMI), physical activity, screen time, mental health, and pet-related questions. Results Children with and children without pet dogs did not differ in BMI (P = .80), screen time of 2 hours or less (P = 0.99), or physical activity (P = .07). A lower percentage of children with dogs (12%) met the clinical cut-off value of Screen for Child Anxiety and Related Disorders (SCARED-5) of 3 or more, compared with children without dogs (21%, P = .002). The mean SCARED-5 score was lower among children with dogs (1.13) compared with children without dogs (1.40; P = .01). This relationship was retained in multivariate analysis after controlling for several covariates. Conclusions Having a pet dog in the home was associated with a decreased probability of childhood anxiety. Future studies need to establish whether this relationship is causal and, if so, how pet dogs alleviate childhood anxiety.

Hie- i —health Information Exchange With Intelligence

This article demonstrates the development and pilot testing of an innovative approach to implement health information exchange with intelligence (HIE-i) in primary care settings. Records of 346 patients were studied in 6 primary care practices. Clinical workflows were evaluated by time motion studies and observations. A viable and sustained HIE connection was adopted by primary care clinicians. Documentation and delivery of several preventive services, medication reconciliation, and workflow efficiency improved. The study was able to establish a sustained and effective HIE implementation. More research is needed to determine the clinical impact and sustainability of the HIE-i approach.

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.

Bridging the gap between public and private healthcare: Influenza-like illness surveillance in a practice-based research network.

This article describes the development, testing, and implementation of the OKAlert-ILI System, a bidirectional, dual-use influenza-like illness surveillance and messaging system, during the influenza seasons of 2003-2004 and 2004-2005 in the Oklahoma Physicians Resource/Research Network, a primary care practice-based research network. We describe how the Oklahoma Physicians Resource/Research Network connected 30 primary care providers to the Oklahoma State Department of Health and how surveillance results were analyzed and fed back to the clinicians on a weekly basis. We demonstrate the timeliness, sensitivity, specificity, acceptability, validity, flexibility, and cost of the system. Finally, we describe upgrades and enhancements to the system based on user evaluation and feedback.

Practice-based Research Networks at the Crossroads of Research Translation

Practice-based research networks (PBRNs) are “experimental farms” for research that matters in clinical practice. One of the defining characteristics of PBRNs is their ability to operate across a wide range of the bidirectional “pipeline of research translation,” from clinical trials to informing health care policy. Developing effective translational approaches requires significant experimentation with new or innovatively combined research methods and theoretical frameworks. While the first decades of PBRN research generated a substantial body of evidence for improving individual practices (horizontal movement), PBRNs now find themselves at the multidimensional crossroads of patient-centeredness and community/population health (vertical movement). This practice-based research theme issue of the Journal of the American Board of Family Medicine provides a rich, cross-sectional synopsis of PBRN activities encompassing T2 translation, core practice-based research, implementation and dissemination research, community practice, and contributions to health care policy.