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  • 1
    In: Medical Care, 2000, Vol.38(2), pp.218-230
    Description: OBJECTIVE.: We evaluated the impact of automated telephone disease management (ATDM) calls with telephone nurse follow-up as a strategy for improving outcomes such as mental health, self-efficacy, satisfaction with care, and health-related quality of life (HRQL) among low-income patients with diabetes mellitus. RESEARCH DESIGN.: This was a randomized, controlled trial. SUBJECTS.: Two hundred forty-eight primarily English- and Spanish-speaking adults with diabetes enrolled at the time of visits to a county health care system. INTERVENTION.: In addition to usual care, intervention patients received biweekly ATDM calls with telephone follow-up by a diabetes nurse educator. Patients used the ATDM calls to report information about their health and self-care and to access self-care education. The nurse used patients' ATDM reports to allocate her time according to their needs. MEASURES.: Patient-centered outcomes were measured at 12 months via telephone interview. RESULTS.: Compared with patients receiving usual care, intervention patients at follow-up reported fewer symptoms of depression (P = 0.023), greater self-efficacy to conduct self-care activities (P = 0.006), and fewer days in bed because of illness (P = 0.026). Among English-speaking patients, those receiving the intervention reported greater satisfaction with their health care overall and with the technical quality of the services they received, their choice of providers and continuity of care, their communication with providers, and the quality of their health outcomes (all P 〈0.042). Intervention and control patients had roughly equivalent scores for established measures of anxiety, diabetes-specific HRQL, and general HRQL. CONCLUSIONS.: This intervention had several positive effects on patient-centered outcomes of care but no measurable effects on anxiety or HRQL.
    Keywords: Medicine ; Public Health;
    ISSN: 0025-7079
    E-ISSN: 15371948
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  • 2
    In: Health Care Management Review, 2018, Vol.43(3), pp.249-260
    Description: BACKGROUND:: The implementation science literature has contributed important insights regarding the influence of formal policies and practices on health care innovation implementation, whereas informal implementation policies and practices have garnered little attention. The broader literature suggests that informal implementation policies and practices could also influence innovation use. PURPOSE:: We used the Organizational Theory of Innovation Implementation to further understand the role of formal and informal implementation policies and practices as determinants of implementation effectiveness. We examined their role within the context of initiatives to increase palliative care consultation in inpatient oncology. METHODS:: We used a case study design in two organizational settings within one academic medical center: medical and gynecologic oncology. We completed semistructured interviews with medical (n = 12) and gynecologic (n = 10) oncology clinicians using questions based on organizational theory. Quantitative data assessed implementation effectiveness, defined as aggregated palliative care consult rates within oncology services from 2010 to 2016. Four palliative care clinicians were interviewed to gain additional implementation context insights. RESULTS:: Medical oncology employed multiple formal policies and practices including training and clinician prompting to support palliative care consultation and a top-down approach, yet most clinicians were unaware of the policies and practices, contributing to a weak implementation climate. In contrast, gynecologic oncology employed one formal policy (written guideline of criteria for initiating a consult) but also relied on informal policies and practices, such as spontaneous feedback and communication; they adopted a bottom-up approach, contributing to broader clinician awareness and strong implementation climate. Both services exhibited variable, increasing consult rates over time. PRACTICE IMPLICATIONS:: Informal policies and practices may compensate or substitute for formal policies and practices under certain conditions (e.g., smaller health care organizations). Further research is needed to investigate the role of formal and informal policies and practices in shaping a strong and sustainable implementation climate and subsequent effective innovation implementation.
    Keywords: Delivery of Health Care ; Implementation Science ; Organizational Innovation ; Referral and Consultation ; Medical Oncology -- Organization & Administration ; Palliative Care -- Organization & Administration;
    ISSN: 0361-6274
    E-ISSN: 15505030
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  • 3
    In: Southern Medical Journal, 1992, Vol.85(7), pp.683-686
    Description: We conducted a statewide survey to identify physiciansʼ experiences, attitudes, and practices related to HIV-infected patients. A random sample, stratified by medical specialty (primary care, surgery, emergency medicine), was drawn. Physicians were concerned about contagion and inadequate knowledge to care for HIV-infected patients; 40% reported refusing or referring new HIV-infected patients. Differences across medical specialty and respondentsʼ interest in various medical education topics to remedy knowledge deficits are discussed.
    Keywords: Empirical Approach ; Health Care and Public Health ; Professional Patient Relationship ; Attitude of Health Personnel ; Health Knowledge, Attitudes, Practice ; HIV Infections -- Therapy ; Physicians -- Psychology;
    ISSN: 0038-4348
    E-ISSN: 15418243
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  • 4
    Language: English
    In: Journal of General Internal Medicine, 2010, Vol.25(3), pp.194-199
    Description: Byline: Erin E. Krebs (1,2,3), Matthew J. Bair (1,2,3), Timothy S. Carey (4,5), Morris Weinberger (6,7) Keywords: pain; measurement; primary care Abstract: BACKGROUND Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management. OBJECTIVES To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered. DESIGN Prospective observational study. PARTICIPANTS 237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week. MEASURES Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month. RESULTS Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k=0.50) and slight for receiving pain management advice (k=0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p=0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p=0.005). CONCLUSIONS Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care. Author Affiliation: (1) Center on Implementing Evidence-Based Practice, Roudebush Veterans Affairs Medical Center, Indianapolis, IN, USA (2) Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA (3) Regenstrief Institute, Inc, Indianapolis, IN, USA (4) Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC, USA (5) Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA (6) Department of Health Policy and Management, University of North Carolina School of Public Health, Chapel Hill, NC, USA (7) Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC, USA Article History: Registration Date: 10/11/2009 Received Date: 13/07/2009 Accepted Date: 09/11/2009 Online Date: 15/12/2009
    Keywords: pain ; measurement ; primary care
    ISSN: 0884-8734
    E-ISSN: 1525-1497
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  • 5
    In: Medical Care, 2001, Vol.39(1), pp.1-3
    Keywords: Internet ; Periodicals As Topic ; Publishing;
    ISSN: 0025-7079
    E-ISSN: 15371948
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  • 6
    In: Medical Care, 1984, Vol.22(8), pp.755-759
    Description: The authors evaluated three methods of referring new hypertensive patients from a large municipal hospital emergency room to an ongoing medical care system. A total of 239 patients were assigned to one of three groups. Compliance with recommendations to receive follow-up care was compared for each group. Forty-two percent of patients who received a routine referral from nurses or physicians plus a follow-up telephone call or letter complied. Thirty percent of patients who received a referral from a specially trained interviewer to the hospitalʼs outpatient assessment area complied. These two groups were not significantly different. Compliance was significantly greater (65%, P 〈 0.001) for a third group of patients who received an appointment from an interviewer to the outpatient general medicine clinic. The appointment was within 3 days from the time of the emergency room visit. An early appointment intervention given to new high blood pressure patients in the emergency room is recommended to improve patient return for follow-up care, thereby improving linkage to an ongoing care system.
    Keywords: Medicine ; Public Health;
    ISSN: 0025-7079
    E-ISSN: 15371948
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  • 7
    In: Medical Care, 1986, Vol.24(3), pp.189-199
    Description: Patients who fail to show for scheduled visits or who fail to contact their provider when warning symptoms occur pose important problems for the primary care physician. A group of interventions was examined to determine the effectiveness in increasing the number of prescribed office visits in patients with diabetes mellitus. This group of interventions included mailed packets with information on how to use the clinic, providersʼ names and phone numbers, after-hours phone numbers, a list of early warning signs, and a booklet on managing diabetes mellitus; mailed appointment reminders; and intense followup of visit failures for prompt rescheduling. Eight hundred fifty-nine patients on drug therapy for diabetes mellitus were stratified by risk of hospitalization and randomly assigned within strata to control and intervention groups. The intervention group received all interventions. After 1 year, the intervention group averaged 12% more total contacts than the control group (5.8 vs. 5.2, P = 0.01), due largely to an increase in kept scheduled visits (4.1 vs. 3.6, P = 0.006). These effects were greatest in those patients at higher risk of hospitalization. Also, visit failures were reduced only in high-risk patients. The effect of the interventions did not diminish during the year of study. This systematic and repetitive intervention appears effective in increasing prescribed office visits and is especially effective in patients requiring more frequent care.
    Keywords: Medicine ; Public Health;
    ISSN: 0025-7079
    E-ISSN: 15371948
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  • 8
    Language: English
    In: Chest, September 2013, Vol.144(3), pp.784-793
    Description: Little is known about the population-based burden of ED care for COPD. We analyzed statewide ED surveillance system data to quantify the frequency of COPD-related ED visits, hospital admissions, and comorbidities. In 2008 to 2009 in North Carolina, 97,511 COPD-related ED visits were made by adults ≥ 45 years of age, at an annual rate of 13.8 ED visits/1,000 person-years. Among patients with COPD (n = 33,799), 7% and 28% had a COPD-related return ED visit within a 30- and 365-day period of their index visit, respectively. Compared with patients on private insurance, Medicare, Medicaid, and noninsured patients were more likely to have a COPD-related return visit within 30 and 365 days and have three or more COPD-related visits within 365 days. There were no differences in return visits by sex. Fifty-one percent of patients with COPD were admitted to the hospital from the index ED visit. Subsequent hospital admission risk in the cohort increased with age, peaking at 65 to 69 years (risk ratio [RR], 1.41; 95% CI, 1.26-1.57); there was no difference by sex. Patients with congestive heart failure (RR, 1.29; 95% CI, 1.22-1.37), substance-related disorders (RR, 1.35; 95% CI, 1.13-1.60), or respiratory failure/supplemental oxygen (RR, 1.25; 95% CI, 1.19-1.31) were more likely to have a subsequent hospital admission compared with patients without these comorbidities. The population-based burden of COPD-related care in the ED is significant. Further research is needed to understand variations in COPD-related ED visits and hospital admissions.
    Keywords: Medicine
    ISSN: 0012-3692
    E-ISSN: 1931-3543
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  • 9
    In: Diabetes Care, August, 1999, Vol.22(8), p.1302
    Description: OBJECTIVEWe examined whether low-income patients with diabetes were able and willing to use automated telephone disease management (ATDM) calls to provide health status information that could improve the quality of their care. RESEARCH DESIGN AND METHODSA total of 252 adults with diabetes, 30 of whom spoke Spanish as their primary language, were enrolled at the time of clinic visits in a Department of Veterans Affairs health care system (n = 132) or a county health care system (n = 120). Patients received ATDM calls for 12 months and responded to queries using their touch-tone telephones. We examined 1) whether patients completed ATDM assessments consistently over the year and used the calls to report their self-monitored blood glucose (SMBG) levels, 2) the characteristics of patients most likely to use the system frequently, 3) whether patients responded consistently within ATDM assessments, and 4) whether ATDM assessments differentiated among groups of patients with different clinical profiles at baseline. RESULTSHalf of all patients completed at least 77% of their attempted assessments, and one-fourth completed at least 91%. Half of all patients reported SMBG levels during at least 86% of their assessments. Patients completed assessments and reported glucose levels consistently over the year. Health status indicators were the most important determinants of assessment completion rates, while socioeconomic factors were more strongly associated with patients' likelihood of reporting SMBG data during assessments. Patients' responses within assessments were consistent, and the information they provided during their initial assessments identified groups with poor glycemic control and other health problems. CONCLUSIONSMost low-income patients with diabetes can and will use ATDM calls as part of their care. The information they provide is reliable and has clinical significance. ATDM calls could improve the information base for diabetes management while relieving some of the pressures of delivering diabetes care under cost constraints.
    Keywords: Diabetes Mellitus -- Care And Treatment ; Poor -- Health Aspects ; Medical Consultation -- Technology Application
    ISSN: 0149-5992
    E-ISSN: 19355548
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  • 10
    Language: English
    In: The American Journal of Cardiology, 15 November 2017, Vol.120(10), pp.1820-1829
    Description: New oral anticoagulants (OACs) and updated risk stratification have the potential to improve the quality of care for patients with atrial fibrillation (AF). To describe the time from AF diagnosis to the initiation of an OAC, characteristics associated with treatment, and the incidence of switching OACs, we conducted this retrospective cohort study of 23,018 adults with incident AF receiving care between 2010 and 2014 in 647 primary care practices participating in the United Kingdom Clinical Practice Research Datalink. In patients with moderate to high stroke risk (CHA DS -VASc ≥ 2), the median time from diagnosis to OAC initiation decreased from 10 to 2 months. Among 980 at very low stroke risk (CHA DS -VASc = 0), 29% received OAC prescriptions after 90 days. Being prescribed an OAC was associated with a history of stroke or transient ischemic attack (relative risk 1.3); severe dementia or psychosis was most associated with not being prescribed an OAC (relative risk 0.3). After 1 year, the risk of OAC switching was higher for patients initiating dabigatran (19%) than warfarin (6%), rivaroxaban (8%), or apixaban (9%). The prescribing of OACs in moderate-to-high-risk patients in the United Kingdom increased annually; 1/3 of very low–risk patients were prescribed OACs contrary to guidance. In conclusion, future research should refine decision-making tools to minimize the unwanted effects of underutilization and overutilization of OACs.
    Keywords: Medicine
    ISSN: 0002-9149
    E-ISSN: 1879-1913
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