Publications by authors named "Andrea Altschuler"

71 Publications

Patient, Family, and Clinician Perspectives on End-of-Life Care Quality Domains and Candidate Indicators for Adolescents and Young Adults With Cancer.

JAMA Netw Open 2021 08 2;4(8):e2121888. Epub 2021 Aug 2.

Division of Research, Kaiser Permanente Northern California, Oakland.

Importance: End-of-life care quality indicators specific to adolescents and young adults (AYAs) aged 12 to 39 years with cancer have not been developed.

Objective: To identify priority domains for end-of-life care from the perspectives of AYAs, family caregivers, and clinicians, and to propose candidate quality indicators reflecting priorities.

Design, Setting, And Participants: This qualitative study was conducted from December 6, 2018, to January 5, 2021, with no additional follow-up. In-depth interviews were conducted with patients, family caregivers, and clinicians and included a content analysis of resulting transcripts. A multidisciplinary advisory group translated priorities into proposed quality indicators. Interviews were conducted at the Dana-Farber Cancer Institute, Kaiser Permanente Northern California, Kaiser Permanente Southern California, and an AYA cancer support community (lacunaloft.org). Participants included 23 AYAs, 28 caregivers, and 29 clinicians.

Exposure: Stage IV or recurrent cancer.

Main Outcomes And Measures: Care priorities.

Results: Interviews were conducted with 23 patients (mean [SD] age, 29.3 [7.3] years; 12 men [52%]; 18 White participants [78%]), 28 family caregivers (23 women [82%]; 14 White participants [50%]), and 29 clinicians (20 women [69%]; 13 White participants [45%]). Caregivers included 22 parents (79%), 5 spouses or partners (18%), and 1 other family member (4%); the 29 clinicians included 15 physicians (52%), 6 nurses or nurse practitioners (21%), and 8 social workers or psychologists (28%). Interviews identified 7 end-of-life priority domains: attention to physical symptoms, attention to quality of life, psychosocial and spiritual care, communication and decision-making, relationships with clinicians, care and treatment, and independence. Themes were consistent across the AYA age range and participant type. Although some domains were represented in quality indicators developed for adults, unique domains were identified, as well as AYA-specific manifestations of existing domains. For example, quality of life included global quality of life; attainment of life goals, legacy, and meaning; support of personal relationships; and normalcy. Within communication and decision-making, domains included communication early in the disease course, addressing prognosis and what to expect at the end of life, and opportunity for AYAs to hold desired roles in decision-making. Care and treatment domains relevant to cancer therapy, use of life-prolonging measures, and location of death emphasized the need for preference sensitivity rather than a standard path. This finding differs from existing adult indicators that propose that late-life chemotherapy, intensive measures, and hospital death should be rare.

Conclusions And Relevance: The findings of this qualitative study suggest that AYAs with cancer have priorities for care at the end of life that are not fully encompassed in existing indicators for adults. Use of new indicators for this young population may better reflect patient- and family-centered experiences of quality care.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.21888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8383130PMC
August 2021

Pediatric Surgeons' Adoption of an Innovative Laparoscopic Technique for Inguinal Hernia Repair: A Mixed Methods Study.

J Laparoendosc Adv Surg Tech A 2021 Aug 27;31(8):947-953. Epub 2021 May 27.

Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.

We studied adoption of an innovative laparoscopic technique for pediatric inguinal hernia repair by pediatric surgeons and pediatric urologists following dissemination of evidence for its benefits. This mixed methods study included children who received inguinal hernia repairs during 2017-2019 and their surgeons. We examined surgeons' adoption and use of the innovative technique and rates of ipsilateral recurrence and metachronous contralateral repair. In-depth interviews with surgeons were used to identify themes regarding attitudes and practices regarding the adoption of surgical innovations. No ipsilateral recurrences were noted among open repairs after 1.5 years of average follow-up, while 1.54% (7/453) of unilateral and 0.50% (3/606 sides) of bilateral innovative surgeries required ipsilateral repair after 1.3 years of average follow-up. Among unilateral cases, metachronous contralateral repairs were performed in 1.63% (8/490) of open and 0.44% (2/453) of innovative surgeries. Surgeon interviews identified approaches to continued learning and change; the role of departmental culture, norms, and resources; and technical issues specific to pediatric surgery and pediatric inguinal hernia repair. Outcomes may have improved over time as a consequence of learning. Differences among surgeons and departments influenced the speed of adoption. Surgeons linked the collegial model used when adopting the new technique to the apprenticeship model used during their training. We propose research into the collegial model to improve translation of evidence-based surgical innovations into practice. Level III.
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http://dx.doi.org/10.1089/lap.2021.0179DOI Listing
August 2021

Implementation of a Multidisciplinary Expert Testicular Cancer Tumor Board Across a Large Integrated Healthcare Delivery System Via Early Case Ascertainment.

JCO Clin Cancer Inform 2021 02;5:187-193

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Purpose: In 2016, Kaiser Permanente Northern California began regionalizing testicular cancer care using population-based tumor board review. This mixed methods evaluation describes implementation outcomes and learnings.

Methods: We conducted in-depth interviews with key stakeholders, administered surveys to local oncologists and urologists, and used clinical data to evaluate changes in care delivery during 2015-2018.

Results: An average of 135 patients with testicular cancer were diagnosed each year. Interviews with 16 key stakeholders provided several insights. Implementation resulted in high levels of satisfaction, was dependent on leadership and staff at various levels, and required technology and consulting solutions aligned to user agreements and clinical workflows. Of 123 local oncologists and urologists who completed surveys, 97% understood why care was regionalized and 89% agreed that tumor board review improved treatment decisions. Among 177 patients with stage I seminoma, the percentage appropriately observed rather than treated with adjuvant chemotherapy or radiation therapy increased from 48% (95% CI, 35 to 62) in 2015 to 87% (75 to 99) in 2018. Review altered care based on pathology and radiology re-review in 14.5 % of cases.

Conclusion: Regionalization was feasible and effective.
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http://dx.doi.org/10.1200/CCI.20.00114DOI Listing
February 2021

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment.

Addict Sci Clin Pract 2021 01 31;16(1). Epub 2021 Jan 31.

Kaiser Permanente Northwest, Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227-1098, USA.

Background: Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here.

Methods: PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16-90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims ("electronic health records," [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization.

Discussion: The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings. Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1.
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http://dx.doi.org/10.1186/s13722-021-00218-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849121PMC
January 2021

Disclosure of New Type 2 Diabetes Diagnoses to Younger Adults: a Qualitative Study.

J Gen Intern Med 2021 06 26;36(6):1622-1628. Epub 2021 Jan 26.

Kaiser Permanente Northern California Division of Research, Oakland, CA, USA.

Background: Adults diagnosed with type 2 diabetes at a younger age are at increased risk for poor outcomes. Yet, little is known about the early experiences of these individuals, starting with communication of the diagnosis. Addressing this knowledge gap is important as this initial interaction may shape subsequent disease-related perceptions and self-management.

Objective: We examined diagnosis disclosure experiences and initial reactions among younger adults with newly diagnosed type 2 diabetes.

Participants: Purposive sample of adult members of Kaiser Permanente Northern California, an integrated healthcare delivery system, diagnosed with type 2 diabetes before age 45 years.

Approach: We conducted six focus groups between November 2017 and May 2018. Transcribed audio recordings were coded by two coders using thematic analysis.

Key Results: Participants (n = 41) were 38.4 (± 5.8) years of age; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified variation in diagnosis disclosure experiences, centered on four key domains: (1) participants' sense of preparedness for diagnosis (ranging from expectant to surprised); (2) disclosure setting (including in-person, via phone, via secure message, or via review of results online); (3) perceived provider tone (from nonchalant, to overly fear-centered, to supportive); and (4) participants' emotional reactions to receiving the diagnosis (including acceptance, denial, guilt, and/or fear, rooted in personal and family experience).

Conclusions: For younger adults, the experience of receiving a diabetes diagnosis varies greatly. Given the long-term consequences of inadequately managed diabetes and the need for early disease control, effective initial disclosure represents an opportunity to optimize initial care. Our results suggest several opportunities to improve the type 2 diabetes disclosure experience: (1) providing pre-test counseling, (2) identifying patient-preferred settings for receiving the news, and (3) developing initial care strategies that acknowledge and address the emotional distress triggered by this life-altering, chronic disease diagnosis.
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http://dx.doi.org/10.1007/s11606-020-06481-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837080PMC
June 2021

Pilot pragmatic randomized trial of mHealth mindfulness-based intervention for advanced cancer patients and their informal caregivers.

Psychooncology 2020 Sep 26. Epub 2020 Sep 26.

Kaiser Permanente Division of Research, Oakland, California, USA.

Objective: Assess the feasibility of conducting a cluster randomized controlled trial (RCT) comparing technology-delivered mindfulness-based intervention (MBI) programs against a waitlist control arm targeting advanced cancer patients and their informal caregivers.

Methods: Two-arm cluster RCT within Kaiser Permanente Northern California. We recruited patients with metastatic solid malignancies or hematological cancers and their informal caregivers. Intervention-group participants chose to use either a commercially available mindfulness app (10-20 min/day) or a webinar-based mindfulness course for 6 weeks. The waitlist control group received usual care. We assessed feasibility measures and obtained participant-reported data on quality of life (QoL; primary outcome) and distress outcomes (secondary) pre- and postintervention.

Results: A hundred and three patients (median age 67 years; 70% female; 81% White) and 39 caregivers (median age 66 years; 79% female; 69% White) were enrolled. Nearly all participants chose the mindfulness app over the webinar-based program. Among the participants in the intervention arm who chose the mobile-app program and completed the postintervention (6-week) survey, 21 (68%) patients and 7 (47%) caregivers practiced mindfulness at least 50% of the days during the 6-week study period. Seventy-four percent of intervention participants were "very" or "extremely" satisfied with the mindfulness program. We observed improvements in anxiety, QoL, and mindfulness among patients in the intervention arm compared to those in the control group.

Conclusions: We demonstrated the feasibility of conducting a cluster RCT of mHealth MBI for advanced cancer patients and their caregivers. Such remote interventions can be helpful particularly during the COVID-19 pandemic.
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http://dx.doi.org/10.1002/pon.5557DOI Listing
September 2020

Primary Care Physicians' Experiences With and Strategies for Managing Electronic Messages.

JAMA Netw Open 2019 12 2;2(12):e1918287. Epub 2019 Dec 2.

The Permanente Medical Group, Oakland, California.

Importance: The increasing use of electronic communications has enhanced access to physicians for patients and clinical staff. Primary care physicians (PCPs) have anecdotally identified electronic inbox management as a new source of work-related stress.

Objectives: To describe PCPs' experiences managing their electronic inboxes and to characterize the array of management strategies developed by individual physicians and practice groups.

Design, Setting, And Participants: This qualitative study was conducted in 8 medical centers of a large group practice with more than 4 million patients in diverse settings and a mature electronic health record. The group encourages patients to use portal secure messaging to enhance access to their physicians and the care experience. Semistructured interviews were conducted with 24 internists and family medicine physicians identified via snowball sampling. Interviews were conducted July through November 2018. Data analysis was conducted between November 2018 and April 2019.

Main Outcomes And Measures: Audio recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes.

Results: The 24 participants (12 women [50.0%]; mean [SD] age, 45.5 [6.5] years), including 9 department chiefs and 15 PCPs, had a mean (SD) of 16.8 (7.8) years since medical school graduation. Participants described substantial changes in medical practice due to electronic communication, including perceived patient expectations to receive rapid responses to portal secure messages. They described portal secure messaging as useful for building relationships with patients, but also reported that electronic message management has created new stressors, including erosion of work-life boundaries and anxiety associated with unlimited inbox volume. Individual PCPs used a diverse array of strategies, including multitasking during and outside work and delegating to medical assistants. Chiefs described group-level strategies, including reserving clinic time for inbox management, coverage systems for vacation and sick days, physician-to-physician training, and interdisciplinary teams to share messaging work.

Conclusions And Relevance: Individual physicians and local practice groups have developed a wide array of strategies for electronic inbox management. The volume of electronic messages and PCPs' perceptions that patients expect rapid responses have created new stressors in primary care practice. Medical groups and health systems can support PCPs by facilitating knowledge transfer among physicians about inbox management strategies and further developing team structures for inbox coverage.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.18287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6991215PMC
December 2019

Cancer Survivorship at the Intersections of Care and Personhood.

Med Anthropol 2020 01 12;39(1):55-68. Epub 2019 Aug 12.

Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Surviving colorectal cancer following ostomy surgery with an intestinal stoma presents numerous challenges to the cultural category of full adult personhood. The foremost is managing unpredictable bowel activity. The technical management of the ostomy facilitated by biomedical specialists, is essential for personhood realignment. This article focuses on how some female long-term cancer survivors manage and adapt to this new fecal habitus by mobilizing various assemblages of care - receiving care, continuing to provide particular gendered forms of care, and returning to caregiving roles. These interdependent practices of care realign personhood, or at the very least, minimize the assaults that having an ostomy presents to the cultural category of full adult personhood.
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http://dx.doi.org/10.1080/01459740.2019.1642886DOI Listing
January 2020

A Randomized Controlled Trial of mHealth Mindfulness Intervention for Cancer Patients and Informal Cancer Caregivers: A Feasibility Study Within an Integrated Health Care Delivery System.

Integr Cancer Ther 2019 Jan-Dec;18:1534735419850634

1 Kaiser Permanente Division of Research, Oakland, CA, USA.

Purpose: To assess feasibility and preliminary efficacy of a mobile/online-based (mHealth) mindfulness intervention for cancer patients and their caregivers to reduce distress and improve quality of life (QoL).

Material And Methods: Two-arm randomized controlled trial within Kaiser Permanente Northern California targeting cancer patients who received chemotherapy and their informal caregivers. The intervention group received a commercially available mindfulness program for 8 weeks. The wait-list control group received usual care. We assessed feasibility using retention and adherence rates and obtained participant-reported data on distress, QoL, sleep, mindfulness, and posttraumatic growth before and immediately after the intervention.

Results: Ninety-seven patients (median age 59 years; female 69%; 65% whites) and 31 caregivers (median age 63 years; female 58%; 77% whites) were randomized. Among randomized participants, 74% of the patients and 84% of the caregivers completed the study. Among those in the intervention arm who initiated the mindfulness program, 65% practiced at least 50% of the days during the intervention period. We observed significantly greater improvement in QoL among patients in the intervention arm compared with controls. Caregivers in the intervention group experienced increased mindfulness compared with controls. Participants appreciated the convenience of the intervention and the mindfulness skills they obtained from the program.

Conclusion: We demonstrated the feasibility of conducting a randomized trial of an mHealth mindfulness intervention for cancer patients and their informal caregivers. Results from fully powered efficacy trials would inform the potential for clinicians to use this scalable intervention to help improve QoL of those affected by cancer and their caregivers.
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http://dx.doi.org/10.1177/1534735419850634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537293PMC
December 2019

Recovering from Cystectomy: Patient Perspectives.

Bladder Cancer 2019 Jan 31;5(1):51-61. Epub 2019 Jan 31.

Division of Research, Kaiser Permanente, Oakland, CA, USA.

Background: Bladder cancer patients who undergo cystectomy and urinary diversion face functional and quality-of-life challenges. Little is known about these patients' experiences during decision-making, surgery, and recovery, or how they vary by treatment setting.

Objective: To learn about patients' experiences with treatment choice, surgical care, and recovery across health settings. Understanding patient experiences is essential to closing care gaps and developing patient-reported measures.

Methods: We conducted focus groups with cystectomy patients and family caregivers at a large comprehensive health care system (N = 32 patients) and an NCI-designated comprehensive cancer center (N = 25 patients and 5 caregivers). Using standard qualitative methods, we identified themes that are not well-represented in existing research.

Results: Across both systems, patients described variable experiences in decision-making about their cystectomy and urinary diversion. Some felt overwhelmed by information; others felt poorly informed. Many found self-care equipment challenging; many felt they knew little about what to expect regarding chemotherapy, recovery, and transitioning home. At times, health care personnel could not help manage patients' ostomies or catheterization equipment. Our study also contributes a grounded theoretical framework for describing meaningful domains of patient experience with cystectomy and urinary diversion. We identified a common trajectory that includes decision-making, surgery and post-operative recovery, mastery of self-care, and reintegration.

Conclusions: Patients with radical cystectomy and urinary diversion report a wide variety of experiences not captured by quantitative measures. These findings demonstrate that many cystectomy patients could benefit from additional post-operative support. We offer a framework to measure patient-centered domains in future research.
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http://dx.doi.org/10.3233/BLC-180202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6401661PMC
January 2019

Prompting Patients with Poorly Controlled Diabetes to Identify Visit Priorities Before Primary Care Visits: a Pragmatic Cluster Randomized Trial.

J Gen Intern Med 2019 06 11;34(6):831-838. Epub 2019 Feb 11.

Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.

Background: Most patients with diabetes do not meet all evidence-based goals of care, and many patients report poor communication and lack of involvement in decision-making during primary care visits.

Objective: To test the hypothesis that a "Pre-Visit Prioritization" secure email message could improve visit communication and glycemic control among patients with type 2 diabetes.

Design: We conducted a pragmatic, provider-randomized, multi-site clinical trial from March 2015 to October 2016 across 30 primary care practices within Kaiser Permanente Northern California (KPNC), a large integrated care delivery system.

Participants: Eligible patients had at least 1 year of KPNC membership, type 2 diabetes with most recently measured hemoglobin A1c (HbA1c) > = 8.0%, and were registered users of the KPNC online patient portal.

Interventions: Patients in the intervention arm, upon booking an appointment, received a secure email through the KPNC online portal with a link to the EHR allowing them to submit their top one or two priorities prior to the visit. Control patients received usual care.

Main Measures: Glycemic control; change in HbA1c 6 and 12 months after the initial visit; patient-reported outcomes related to patient-provider communication and patient care experiences.

Key Results: During the study period, 1276 patients had at least one eligible visit. In post-visit surveys (n = 457), more intervention arm patients reported preparing questions for their visit (72% vs 63%, p = 0.048) and being given treatment choices to consider (81% vs 73%, p = 0.041). Patients in both arms had similar reductions in HbA1c over the 12-month study period (0.56% ± 1.45%), with no significant differences between arms.

Conclusions: A "light touch" email-based pre-visit intervention resulted in improved measures of visit interaction but did not significantly improve glycemic control relative to usual care. Improving diabetes clinical outcomes through more effective primary care visits may require more intensive approaches to patient visit preparation.

Trial Registry: NCT02375932.
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http://dx.doi.org/10.1007/s11606-018-4756-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544732PMC
June 2019

Predictors of Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement among patients with opioid use disorder across 7 health systems.

Subst Abus 2019 24;40(3):328-334. Epub 2019 Jan 24.

Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.

The prevalence of opioid use disorder (OUD) has increased rapidly in the United States and improving treatment access is critical. Among patients with OUD, we examined factors associated with the Healthcare Effectiveness Data and Information Set (HEDIS) performance measures of alcohol and other drug (AOD) treatment initiation and engagement. Electronic health record and claims data between October 1, 2014, and August 15, 2015, from 7 health systems were used to identify patients ( = 11,490) with a new index OUD diagnosis (no AOD diagnosis prior <60 days) based on International Classification of Diseases (ICD)-9 codes. Multivariable generalized linear models with a logit link clustered on health system were used to examine the associations of patient demographic and clinical characteristics, and department of index diagnosis, with HEDIS measures of treatment initiation and engagement. The prevalence of OUD among all AOD diagnoses varied across health systems, as did rates of AOD initiation (5.7%-21.6%) and engagement (7.6%-24.6%). Those diagnosed in the emergency department (adjusted odds ratio [aOR] = 1.58, 95% confidence interval [CI] = 1.27,1.97) or psychiatry/AOD treatment (aOR = 2.92, 95% CI = 2.47,3.46) were more likely to initiate treatment compared with primary care. Older patients were less likely to initiate (age 50-64 vs. age 18-29: aOR = 0.42, 95% CI = 0.35, 0.51; age 65+ vs. age 18-29: aOR = 0.34, 95% CI = 0.26, 0.43), as were women (aOR = 0.72, 95% CI = 0.62, 0.85). Patients diagnosed in psychiatry/AOD treatment (aOR = 2.67, 95% CI = 1.98, 3.60) compared with primary care were more likely to engage in treatment. Those identified in an inpatient setting (aOR = 0.19, 95% CI = 0.14, 0.27 vs. primary care), those with medical comorbidity (aOR = 0.70, 95% CI = 0.52, 0.95), and older patients (age 50-64 vs. 18-29: aOR = 0.64, 95% CI = 0.46, 0.88; age 65+ vs. 18-29: aOR = 0.36, 95% CI = 0.22, 0.57) were less likely to engage in treatment. Rates of initiation and engagement for OUD patients vary widely with noticeable room for improvement, particularly in this critical time of the opioid crisis. Targeting patient and system factors may improve health system performance, which is key to improving patient outcomes.
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http://dx.doi.org/10.1080/08897077.2018.1545729DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859006PMC
July 2020

Factors associated with Healthcare Effectiveness Data and Information Set (HEDIS) alcohol and other drug measure performance in 2014-2015.

Subst Abus 2019 24;40(3):318-327. Epub 2019 Jan 24.

Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.

Only 10% of patients with alcohol and other drug (AOD) disorders receive treatment. The AOD Initiation and Engagement in Treatment (AOD-IET) measure was added to the national Healthcare Effectiveness Data and Information Set (HEDIS) to improve access to care. This study identifies factors related to improving AOD-IET rates. We include data from 7 health systems with differing geographic, patient demographic, and organizational characteristics; all used a common Virtual Data Warehouse containing electronic health records and insurance claims data. Multilevel logistic regression models examined AOD-IET among adults (18+). A total of 86,565 patients had an AOD diagnosis qualifying for the HEDIS denominator. The overall initiation rate was 27.9% with wide variation; the overall engagement rate was 11.5% and varied from 4.5% to 17.9%. Women versus men (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.76-0.86); Hispanics (OR = 0.85, 95% CI = 0.79-0.91), black/African Americans (OR = 0.82, 95% CI = 0.75-0.90), and Asian Americans (OR = 0.83, 95% CI = 0.72-0.95) versus whites; and patients aged 65+ versus 18-29 (OR = 0.82, 95% CI = 0.74-0.90) had lower odds of initiation. Patients aged 30-49 versus 18-29 (OR = 1.11, 95% CI = 1.04-1.19) and those with prior psychiatric (OR = 1.26, 95% CI = 1.18-1.35) and medical (OR = 1.18, 95% CI = 1.10-1.26) conditions had higher odds of initiation. Identification in primary care versus other departments was related to lower odds of initiation (emergency department [ED]: OR = 1.55, 95% CI = 1.45-1.66; psychiatry/AOD treatment: OR = 3.58, 95% CI = 3.33-3.84; other outpatient: OR = 1.19, 95% CI = 1.06-1.32). Patients aged 30-49 versus 18-29 had higher odds of engagement (OR = 1.26, 95% CI = 1.10-1.43). Patients aged 65+ versus 18-29 (OR = 0.51, 95% CI = 0.43-0.62) and black/African Americans versus whites (OR = 0.64, 95% CI = 0.53-0.77) had lower odds. Those initiating treatment in psychiatry/AOD treatment versus primary care (OR = 7.02, 95% CI = 5.93-8.31) had higher odds of engagement; those in inpatient (OR = 0.40, 95% CI = 0.32-0.50) or other outpatient (OR = 0.73, 95% CI = 0.59-0.91) settings had lower odds. : Rates of initiation and engagement varied but were low. Findings identified age, race/ethnicity, co-occurring conditions, and department of identification as key factors associated with AOD-IET. Focusing on these could help programs develop interventions that facilitate AOD-IET for those less likely to receive care.
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http://dx.doi.org/10.1080/08897077.2018.1545728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6656639PMC
July 2020

Characteristics of patients with substance use disorder before and after the Affordable Care Act.

Drug Alcohol Depend 2018 12 6;193:124-130. Epub 2018 Oct 6.

Division of Research, Kaiser Permanente Northern California Region, 2000 Broadway, 3rdFloor, Oakland, CA, 94612, USA; Department of Psychiatry, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA, 94143, USA.

Background: The Affordable Care Act (ACA) offered an unprecedented opportunity to expand insurance coverage to patients with substance use disorders (SUDs). We explored the expectations of key stakeholders for the ACA's impact on SUD care, and examined how clinical characteristics of newly enrolled patients with SUD in a large healthcare delivery system differed pre- and post- ACA implementation.

Methods: In this mixed-methods study, qualitative interviews were conducted with health system leaders to identify themes regarding how the health system prepared for the ACA. Electronic health record data were used to examine demographics, as well as specific SUD, psychiatric, and medical diagnoses in cohorts of pre-ACA (2012, n = 6066) vs. post-ACA (2014, n = 7099) newly enrolled patients with SUD. Descriptive statistics and logistic regression models were employed to compare pre-ACA and post-ACA measures.

Results: Interviewees felt much uncertainty, but anticipated having to care for more SUD patients, who might have greater severity. Quantitative findings affirmed these expectations, with post-ACA SUD patients having higher rates of cannabis and amphetamine use disorders, and more psychiatric and medical conditions, compared to their pre-ACA counterparts. The post-ACA SUD cohort also had more Medicaid patients and greater enrollment in high-deductible plans.

Conclusions: Post-ACA, SUD patients had more comorbidities as well as and more financial barriers to care. As federal healthcare policy continues to evolve, with potentially more restrictive coverage criteria, it is essential to continue examining how health systems adapt to changing health policy and its impact on SUD care.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.08.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703160PMC
December 2018

Being Present: A single-arm feasibility study of audio-based mindfulness meditation for colorectal cancer patients and caregivers.

PLoS One 2018 23;13(7):e0199423. Epub 2018 Jul 23.

Department of Medicine and Helen Diller Family Comprehensive Cancer Center (HFCCC), University of California, San Francisco (UCSF), San Francisco, California, United States of America.

A metastatic cancer diagnosis is associated with high levels of distress in patients and caregivers. Mindfulness interventions can reduce distress and improve quality of life in cancer patients. However, standard mindfulness training relies on in-person instruction, which is often not practical for either patients receiving chemotherapy or their caregivers. In the Being Present single arm pilot study, we designed and tested an 8-week audio-based mindfulness meditation program for patients with metastatic colorectal cancer receiving chemotherapy with or without a participating caregiver. The study accrued 33 of 74 (45%) eligible patients consenting together with 20 family caregivers (53 participants total) within nine months. Forty-one participants were evaluable (77%); 10 of 12 cases of attrition were attributable to hospitalization or death. Median participant age was 51 (range 21-78 years); 38% were men. Baseline levels of distress were similar in patients and caregivers. The top reasons for participation cited in pre-intervention interviews were to increase relaxation/calm, improve mood/emotions, and reduce stress/anxiety. In measures of adherence, 59% of responses to weekly texts asking: "Have you practiced today?" were "Yes" and 59% of interviewees reported practicing >50% of the time. Compared to baseline, post-intervention surveys demonstrated significantly reduced distress (p = 0.01) and anxiety (p = 0.03); as well as increased non-reactivity (p<0.01), and feeling at peace (p<0.01). Post-intervention qualitative interviews, where 71% of participants reported benefit, were consistent with quantitative findings. In the interviews, participants spontaneously described reduced stress/anxiety and increased relaxation/calm. Benefits appeared to be accentuated in patient-caregiver pairs as compared to unpaired patients. Seventy-nine percent of participants reported plans for continued practice after study completion. We conclude that the Being Present audio-based mindfulness meditation program is of interest to, feasible, and acceptable for patients with metastatic colorectal cancer and caregivers, with initial evidence of efficacy. These results will guide plans for a follow-up study.

Trial Registration: ClinicalTrials.gov NCT02423720.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199423PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6056029PMC
January 2019

'The Hand on the Doorknob': Visit Agenda Setting by Complex Patients and Their Primary Care Physicians.

J Am Board Fam Med 2018 Jan-Feb;31(1):29-37

From the Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI (CPK, MH); Institute for Health Research, Kaiser Permanente Colorado, Denver, CO (DBM, EAB); Division of Research, Kaiser Permanente-Northern California, Oakland, CA (NC, AA, CSU, RWG); Center for Vulnerable Populations, University of California-San Francisco, San Francisco (CL); Department of Family Medicine, University of Colorado School of Medicine, Aurora (EAB); Department of Internal Medicine, University of Michigan, Ann Arbor (MH).

Background: Choosing which issues to discuss in the limited time available during primary care visits is an important task for complex patients with chronic conditions.

Design, Setting, And Participants: We conducted sequential interviews with complex patients (n = 40) and their primary care physicians (n = 17) from 3 different health systems to investigate how patients and physicians prepare for visits, how visit agendas are determined, and how discussion priorities are established during time-limited visits.

Key Results: Visit flow and alignment were enhanced when both patients and physicians were effectively prepared before the visit, when the patient brought up highest-priority items first, the physician and patient worked together at the beginning of the visit to establish the visit agenda, and other team members contributed to agenda setting. A range of factors were identified that undermined the ability of patient and physicians to establish an efficient working agenda: the most prominent were time pressure and short visit lengths, but also included differing visit expectations, patient hesitancy to bring up embarrassing concerns, electronic medical record/documentation requirements, differences balancing current symptoms versus future medical risk, nonactionable items, differing philosophies about medications and lifestyle interventions, and difficulty by patients in prioritizing their top concerns.

Conclusions: Primary care patients and their physicians adopt a range of different strategies to address the time constraints during visits. The primary factor that supported well-aligned visits was the ability for patients and physicians to proactively negotiate the visit agenda at the beginning of the visit. Efforts to optimize care within time-constrained systems should focus on helping patients more effectively prepare for visits. Physicians should ask for the patient's agenda early, explain visit parameters, establish a reasonable number of concerns that can be discussed, and collaborate on a plan to deal with concerns that cannot be addressed during the visit.
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http://dx.doi.org/10.3122/jabfm.2018.01.170167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5893137PMC
August 2019

Rectal Cancer Survivors' Participation in Productive Activities.

Perm J 2018 ;22:17-022

Instructor of Surgery at the University of Pennslvania School of Medicine and Chief of Surgery for the CMC Veterans Affairs Medical Center in Philadelphia.

Context: Rectal cancer and its treatment impair survivors' productivity.

Objective: To assess determinants of market and nonmarket employment, job search, volunteering, and homemaking among survivors five years or longer after diagnosis.

Design: We mailed questionnaires to 1063 survivors who were members of Kaiser Permanente (Northern California, Northwest) during 2010 and 2011.

Main Outcome Measures: Productive activities, functional health status, and bowel management at the time of the survey.

Results: Response rate was 60.5% (577/953). Higher comorbidity burdens were associated with lower productivity for men and women rectal cancer survivors. Productive survivors were younger and had lower disease stage and age at diagnosis, higher household income and educational attainment, and fewer comorbidity burdens and workplace adjustments than did nonproductive survivors (p < 0.05 each; 2-sided). Productive rectal cancer survivors were evenly split by sex.

Conclusion: Staying productive is associated with better mental health for rectal cancer survivors. Rectal cancer survivors with multiple chronic conditions, higher disease stage, lower productive activities, and older age need better access to medical care and closer monitoring of the quality of their care, including self-care. To capture the full extent of the involvement of survivors in all types of productive activities, research should routinely include measures of employment, searching for employment, homemaking, and volunteering. Counting market and nonmarket productive activities is innovative and recognizes the continuum of contributions survivors make to families and society. Health care systems should routinely monitor rectal cancer survivors' medical care access, comorbidities, health-related quality of life, and productive activities.
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http://dx.doi.org/10.7812/TPP/17-022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5737923PMC
July 2018

Influence of Language and Culture in the Primary Care of Spanish-Speaking Latino Adults with Poorly Controlled Diabetes: A Qualitative Study.

Ethn Dis 2017 7;27(4):379-386. Epub 2017 Dec 7.

Division of Research, Kaiser Permanente Northern California, Oakland, CA.

Background: We examined the role of language and culture in the interactions between Spanish-speaking Latino patients with poorly controlled diabetes - a fast-growing population in the United States - and their primary care providers.

Methods: We conducted four focus groups with 36 non-US born Spanish-speaking patients with elevated HbA1c. Participants were insured health plan members with either English-speaking (2 groups) or Spanish-speaking (2 groups) primary care providers. Moderated discussions focused on visit preparation, communication during visit, and role of other care team members. Key themes derived from these discussions were then linked to corresponding Latino cultural constructs.

Results: Patients had a mean age of 57.9 (±11.2) years and last measured HbA1c was 8.6% (1.5%). Two communication-related themes (reluctance to switch providers and use of intermediaries) and two visit-related themes (provider-driven visit agendas and problem-based visits) emerged from our analyses. These themes reflected the cultural constructs of confianza (trust), familismo (family), respeto (deference), and simpatía (harmonious relationship). Trust in the patient-provider relationship led many participants to remain with English-speaking providers who treated them well. Patients with either language concordant and discordant providers reported reliance on family or other intermediaries to close communication gaps. Deference to physician expertise and authority led to visit expectations that it is the doctor's job to know what to ask and that visits were intended to address specific, often symptom-driven problems.

Conclusions: Spanish-speaking Latino patients' cultural expectations play an important role in framing their primary care interactions. Recognizing culturally influenced visit expectations is an important step toward improving patient-provider communication.
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http://dx.doi.org/10.18865/ed.27.4.379DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5720947PMC
July 2019

Caregiving and mutuality among long-term colorectal cancer survivors with ostomies: qualitative study.

Support Care Cancer 2018 02 26;26(2):529-537. Epub 2017 Aug 26.

Kaiser Permanente Center for Health Research, 3800 N. Interstate Avenue, Portland, OR, 97227, USA.

Purpose: The cancer caregiving literature focuses on the early phases of survivorship, but caregiving can continue for decades when cancer creates disability. Survivors with an ostomy following colorectal cancer (CRC) have caregiving needs that may last decades. Mutuality has been identified as a relationship component that can affect caregiving. This paper discusses how mutuality may affect long-term ostomy caregiving.

Methods: We conducted semi-structured, in-depth interviews with 31 long-term CRC survivors with ostomies and their primary informal caregivers. Interviewees were members of an integrated health care delivery system in the USA. We used inductive theme analysis techniques to analyze the interviews.

Results: Most survivors were 71 years of age or older (67%), female (55%), and with some college education (54%). Two thirds lived with and received care from spouses. Caregiving ranged from minimal support to intimate assistance with daily ostomy care. While some survivors received caregiving far beyond what was needed, others did not receive adequate caregiving for their health care needs. Low mutuality created challenges for ostomy caregiving.

Conclusions: Mutuality impacts the quality of caregiving, and this quality may change over time, depending on various factors. Emotional feedback and amplification is the proposed mechanism by which mutuality may shift over time. Survivorship care should include assessment and support of mutuality as a resource to enhance health outcomes and quality of life for survivors with long-term caregiving needs and their caregivers. Appropriate questionnaires can be identified or developed to assess mutuality over the survivorship trajectory.
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http://dx.doi.org/10.1007/s00520-017-3862-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5767474PMC
February 2018

Participation in Activities Associated With Quality of Life for Long-Term Survivors of Rectal Cancer.

Perm J 2017 ;21:16-011

Research Scientist for the Division of Research in Oakland, CA.

Context: Cancer patients' participation in social, recreational, and civic activities is strongly associated with quality of life (QOL), but these activities are not well integrated into cancer survivorship research or interventions.

Objective: Test the hypothesis that for long-term (≥ 5 years) survivors of rectal cancer, clinical factors (type of surgery and bowel function) are associated with long-term participation in activities and that participation in activities is associated with long-term QOL.

Design: Observational study with longitudinal and cross-sectional components.

Main Outcome Measures: Participation in activities and QOL. Tumor registry records were used to identify patients and obtain clinical data; surveys assessed participation and QOL. Using general linear models, we analyzed participation in activities in relation to type of surgery and bowel function after adjustment for potential confounders. We analyzed overall QOL relative to participation in activities after adjustment.

Results: A total of 567 rectal cancer survivors completed a mailed questionnaire. Overall response rate was 61%. The type of operation (p < 0.0001), receipt of radiation therapy (p = 0.002), and bowel function (p < 0.0001) were associated with participation in activities. Participation in activities was the strongest predictor of QOL (p < 0.0001), explaining 20% of the variance (R) in QOL, with all other variables together accounting for another 18% of the variance.

Conclusion: The importance of participation in activities on rectal cancer survivors' QOL is underappreciated. We recommend revising QOL instruments used in cancer care and research to include questions about participation in activities. Interventions should address maintenance of preferred activities and adoption of new, fulfilling activities.
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http://dx.doi.org/10.7812/TPP/16-011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5283789PMC
September 2017

Primary care visit preparation and communication for patients with poorly controlled diabetes: A qualitative study of patients and physicians.

Prim Care Diabetes 2017 04 1;11(2):148-153. Epub 2016 Dec 1.

University of Michigan Department of Internal Medicine, Ann Arbor, USA.

Objective: The purpose of this study was to examine how patients with diabetes and their primary care physicians identify and discuss visit priorities prior to and during visits.

Methods: We conducted a qualitative study involving patients with diabetes (4 focus groups, n=29) and primary care physicians (6 provider practice meeting discussions, n=67).

Results: Four key themes related to prioritization were identified: 1) the value of identifying visit priorities before the visit; 2) challenges to negotiating priorities during the time-limited visit; 3) the importance of "non-medical" priorities; and 4) the need for strategies to help patients prepare for visits. Both patients and physicians felt that identifying a concise list of key priorities in advance of the visit could help establish collaborative visit agendas and treatment plans.

Conclusions: Identifying and communicating mutually agreed upon priorities for discussion is a key challenge for time-limited primary care visits.

Practice Implications: Communication between primary care physicians and their patients with diabetes could be improved by strategies that help patients identify their top visit priorities before the visit.
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http://dx.doi.org/10.1016/j.pcd.2016.11.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340584PMC
April 2017

Implementation and Operational Research: Affordable Care Act Implementation in a California Health Care System Leads to Growth in HIV-Positive Patient Enrollment and Changes in Patient Characteristics.

J Acquir Immune Defic Syndr 2016 Dec;73(5):e76-e82

*Department of Psychiatry, UCSF Weill Institute for Neurosciences, University of California San Francisco, San Francisco, CA; †Division of Research, Kaiser Permanente, Oakland, CA; and ‡AIDS Research Institute, University of California San Francisco, San Francisco, CA.

Objectives: This study examined implementation of the Affordable Care Act (ACA) in relation to HIV-positive patient enrollment in an integrated health care system; as well as changes in new enrollee characteristics, benefit structure, and health care utilization after key ACA provisions went into effect in 2014.

Methods: This mixed-methods study was set in Kaiser Permanente Northern California (KPNC). Qualitative interviews with 29 KPNC leaders explored planning for ACA implementation. Quantitative analyses compared newly enrolled HIV-positive patients in KPNC between January and December 2012 ("pre-ACA," N = 661) with newly enrolled HIV-positive patients between January and December 2014 ("post-ACA," N = 880) on demographics; medical, psychiatric, and substance use disorder diagnoses; HIV clinical indicators; and type of health care utilization.

Results: Interviews found that ACA preparation focused on enrollment growth, staffing, competition among health plans, concern about cost sharing, and HIV pre-exposure prophylaxis (PrEP) services. Quantitative analyses found that post-ACA HIV-positive patient enrollment grew. New enrollees in 2014 were more likely than 2012 enrollees to be enrolled in high-deductible plans (P < 0.01) or through Medicaid (P < 0.01), and marginally more likely to have better HIV viral control (P < 0.10). They also were more likely to be diagnosed with asthma (P < 0.01) or substance use disorders (P < 0.05) and to have used primary care health services in the 6 months postenrollment (P < 0.05) than the pre-ACA cohort.

Conclusions: As anticipated by KPNC interviewees, ACA implementation was followed by HIV-positive patient enrollment growth and changing benefit structures and patient characteristics. Although HIV viral control improved, comorbid diagnosis findings reinforced the importance of coordinated health care.
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http://dx.doi.org/10.1097/QAI.0000000000001188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5110373PMC
December 2016

Greatest Challenges of Rectal Cancer Survivors: Results of a Population-Based Survey.

Dis Colon Rectum 2016 Nov;59(11):1019-1027

1 Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon 2 Division of Research, Kaiser Permanente Medical Care Program, Oakland, California 3 Southern Arizona Veterans Affairs Health Care System and University of Arizona College of Medicine, Tucson, Arizona 4 Division of Nursing Research and Education, Department of Population Sciences, City of Hope, Duarte, California.

Background: Eliciting the priorities of cancer survivors is essential to address the specific needs of cancer survivor subgroups.

Objective: The purpose of this study was to describe the greatest challenges related to treatment for long-term rectal cancer survivors.

Design: This was an observational study with a cross-sectional survey.

Settings: The study included members of Kaiser Permanente Northern California and Northwest health plans.

Patients: A survey was mailed to long-term (≥5 years postdiagnosis) survivors of rectal cancer who had an anastomosis, temporary ostomy, or permanent ostomy.

Main Outcome Measures: The main outcome was measured with an open-ended question about the greatest challenge related to cancer surgery. We categorized responses using a grounded theory approach with double coding for reliability. Bonferroni-adjusted χ values were used to assess differences in the proportions of subgroups who mentioned challenges within each response category.

Results: The survey completion rate was 61% (577/953); 76% (440/577) of participants responded to the greatest challenge question. The greatest challenges for respondents were bowel/ostomy management (reported by 44%), negative psychosocial effects (37%), late effects of treatment (21%), comorbidities and aging (13%), postoperative recovery (5%), and negative healthcare experiences (5%). Survivors with temporary ostomy or anastomosis were more likely than survivors with permanent ostomy to report late effects (p < 0.0001 and p = 0.01). Survivors with anastomosis were less likely than survivors with permanent ostomy to report negative psychosocial impacts (p = 0.0001).

Limitations: Generalizability is restricted by the lack of ethnically and racially diverse, uninsured (non-Medicare-eligible population), and non-English-speaking participants. Because the survey was cross-sectional and included respondents at different times since diagnosis, we could not adequately address changes in the greatest challenges over time.

Conclusions: Our results reveal the need for bowel/ostomy management, psychosocial services, and surveillance for late effects in survivorship and supportive care services for all survivors of rectal cancer, regardless of ostomy status. The perspective of long-term survivors with anastomosis reveals challenges that may not be anticipated during decision making for treatment (see Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A254).
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http://dx.doi.org/10.1097/DCR.0000000000000695DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5226258PMC
November 2016

User-Centered Design of a Tablet Waiting Room Tool for Complex Patients to Prioritize Discussion Topics for Primary Care Visits.

JMIR Mhealth Uhealth 2016 Sep 14;4(3):e108. Epub 2016 Sep 14.

Center for Vulnerable Populations, Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States.

Background: Complex patients with multiple chronic conditions often face significant challenges communicating and coordinating with their primary care physicians. These challenges are exacerbated by the limited time allotted to primary care visits.

Objective: Our aim was to employ a user-centered design process to create a tablet tool for use by patients for visit discussion prioritization.

Methods: We employed user-centered design methods to create a tablet-based waiting room tool that enables complex patients to identify and set discussion topic priorities for their primary care visit. In an iterative design process, we completed one-on-one interviews with 40 patients and their 17 primary care providers, followed by three design sessions with a 12-patient group. We audiorecorded and transcribed all discussions and categorized major themes. In addition, we met with 15 key health communication, education, and technology leaders within our health system to further review the design and plan for broader implementation of the tool. In this paper, we present the significant changes made to the tablet tool at each phase of this design work.

Results: Patient feedback emphasized the need to make the tablet tool accessible for patients who lacked technical proficiency and to reduce the quantity and complexity of text presentation. Both patients and their providers identified specific content choices based on their personal experiences (eg, the ability to raise private or sensitive concerns) and recommended targeting new patients. Stakeholder groups provided essential input on the need to augment text with video and to create different versions of the videos to match sex and race/ethnicity of the actors with patients.

Conclusions: User-centered design in collaboration with patients, providers, and key health stakeholders led to marked evolution in the initial content, layout, and target audience for a tablet waiting room tool intended to assist complex patients with setting visit discussion priorities.
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http://dx.doi.org/10.2196/mhealth.6187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5040865PMC
September 2016

Demographic, Insurance, and Health Characteristics of Newly Enrolled HIV-Positive Patients After Implementation of the Affordable Care Act in California.

Am J Public Health 2016 07 14;106(7):1211-3. Epub 2016 Apr 14.

All of the authors are affiliated with the Division of Research, Kaiser Permanente Northern California Region, Oakland. Derek D. Satre is also with the Department of Psychiatry, University of California, San Francisco.

Objectives: To examine changes in HIV-positive patient enrollment in a large health care delivery system before and after key Affordable Care Act (ACA) provisions went into effect in 2014.

Methods: Analyses compared HIV-positive patients newly enrolled in Kaiser Permanente Northern California between January and June 2012 (n = 339) to those newly enrolled between January and June 2014 through the California insurance exchange or via other mechanisms (n = 549).

Results: After the ACA, the HIV-positive patient enrollment increased. These new enrollees were more likely to be male (93.6% vs 89.1%; P = .01), to be enrolled in high-deductible benefit plans (≥ $1000; 18.8% vs 5.5%; P = .01), and to have better HIV viral control (HIV RNA levels below limits of quantification 79.5% vs 73.6%; P = .05) compared with pre-ACA new enrollees. Among post-ACA new enrollees, there were more patients in the lowest and highest age groups. Post-ACA exchange enrollees (22%) were more likely to be male and to have high-deductible plans than those enrolled through other mechanisms.

Conclusions: More men, higher deductibles, and better HIV viral control characterize newly enrolled HIV-positive patients after the ACA in California.

Public Health Implications: Evolving characteristics of HIV-positive enrollees may affect HIV policy, patient care needs, and service utilization.
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http://dx.doi.org/10.2105/AJPH.2016.303126DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902724PMC
July 2016

The Diabetes Telephone Study: Design and challenges of a pragmatic cluster randomized trial to improve diabetic peripheral neuropathy treatment.

Clin Trials 2016 06 31;13(3):286-93. Epub 2016 Mar 31.

Division of Research, Kaiser Permanente, Oakland, CA, USA.

Background: Challenges to effective pharmacologic management of symptomatic diabetic peripheral neuropathy include the limited effectiveness of available medicines, frequent side effects, and the need for ongoing symptom assessment and treatment titration for maximal effectiveness. We present here the rationale and implementation challenges of the Diabetes Telephone Study, a randomized trial designed to improve medication treatment, titration, and quality of life among patients with symptomatic diabetic peripheral neuropathy.

Methods: We implemented a pragmatic cluster randomized controlled trial to test the effectiveness of an automated interactive voice response tool designed to provide physicians with real-time patient-reported data about responses to newly prescribed diabetic peripheral neuropathy medicines. A total of 1834 primary care physicians treating patients in the diabetes registry at Kaiser Permanente Northern California were randomized into the intervention or control arm. In September 2014, we began identification and recruitment of patients assigned to physicians in the intervention group who receive three brief interactive calls every 2 months after a medication is prescribed to alleviate diabetic peripheral neuropathy symptoms. These calls provide patients with the opportunity to report on symptoms, side effects, self-titration of medication dose and overall satisfaction with treatment. We plan to compare changes in self-reported quality of life between the intervention group and patients in the control group who receive three non-interactive automated educational phone calls.

Results: Successful implementation of this clinical trial required robust stakeholder engagement to help tailor the intervention and to address pragmatic concerns such as provider time constraints. As of 27 October 2015, we had screened 2078 patients, 1447 of whom were eligible for participation. We consented and enrolled 1206 or 83% of those eligible. Among those enrolled, 53% are women and the mean age is 67 (standard deviation = 12) years. The racial ethnic make-up is 56% White, 8% Asian, 13% Black or African American, and 19% Hispanic or Latino.

Conclusion: Innovative strategies are needed to guide improvements in healthcare delivery for patients with symptomatic diabetic peripheral neuropathy. This trial aims to assess whether real-time collection and clinical feedback of patient treatment experiences can reduce patient symptom burden. Implementation of a clinical trial closely involving clinical care required researchers to partner with clinicians. If successful, this intervention provides a critical information feedback loop that would optimize diabetic peripheral neuropathy medication titration through widely available interactive voice response technology.
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http://dx.doi.org/10.1177/1740774516631530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261503PMC
June 2016

Conversations for providers caring for patients with rectal cancer: Comparison of long-term patient-centered outcomes for patients with low rectal cancer facing ostomy or sphincter-sparing surgery.

CA Cancer J Clin 2016 09 21;66(5):387-97. Epub 2016 Mar 21.

Staff General and Oncologic Surgeon, Professor of Surgery, Southern Arizona Veterans Affairs Health Care System and University of Arizona College of Medicine, Tucson, AZ.

For some patients with low rectal cancer, ostomy (with elimination into a pouch) may be the only realistic surgical option. However, some patients have a choice between ostomy and sphincter-sparing surgery. Sphincter-sparing surgery has been preferred over ostomy because it offers preservation of normal bowel function. However, this surgery can cause incontinence and bowel dysfunction. Increasingly, it has become evident that certain patients who are eligible for sphincter-sparing surgery may not be well served by the surgery, and construction of an ostomy may be better. No validated assessment tool or decision aid has been published to help newly diagnosed patients decide between the two surgeries or to help physicians elicit long-term surgical outcomes. Furthermore, comparison of long-term outcomes and late effects after the two surgeries has not been synthesized. Therefore, this systematic review summarizes controlled studies that compared long-term survivorship outcomes between these two surgical groups. The goals are: 1) to improve understanding and shared decision-making among surgeons, oncologists, primary care providers, patients, and caregivers; 2) to increase the patient's participation in the decision; 3) to alert the primary care provider to patient challenges that could be addressed by provider attention and intervention; and 4) ultimately, to improve patients' long-term quality of life. This report includes discussion points for health care providers to use with their patients during initial discussions of ostomy and sphincter-sparing surgery as well as questions to ask during follow-up examinations to ascertain any long-term challenges facing the patient. CA Cancer J Clin 2016;66:387-397. © 2016 American Cancer Society.
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http://dx.doi.org/10.3322/caac.21345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5618707PMC
September 2016

Pre-Visit Prioritization for complex patients with diabetes: Randomized trial design and implementation within an integrated health care system.

Contemp Clin Trials 2016 Mar 26;47:196-201. Epub 2016 Jan 26.

University of Michigan, Department of Internal Medicine, Ann Arbor, MI, United States; Center for Clinical Management Research, Ann Arbor VA, Ann Arbor, MI, United States.

Background/aims: Despite robust evidence to guide clinical care, most patients with diabetes do not meet all goals of risk factor control. Improved patient-provider communication during time-limited primary care visits may represent one strategy for improving diabetes care.

Methods: We designed a controlled, cluster-randomized, multi-site intervention (Pre-Visit Prioritization for Complex Patients with Diabetes) that enables patients with poorly controlled type 2 diabetes to identify their top priorities prior to a scheduled visit and sends these priorities to the primary care physician progress note in the electronic medical record. In this paper, we describe strategies to address challenges to implementing our health IT-based intervention study within a large health care system.

Results: This study is being conducted in 30 primary care practices within a large integrated care delivery system in Northern California. Over a 12-week period (3/1/2015-6/6/2015), 146 primary care physicians consented to enroll in the study (90.1%) and approved contact with 2496 of their patients (97.6%). Implementation challenges included: (1) navigating research vs. quality improvement requirements; (2) addressing informed consent considerations; and (3) introducing a new clinical tool into a highly time-constrained workflow. Strategies for successfully initiating this study included engagement with institutional leaders, Institutional Review Board members, and clinical stakeholders at multiple stages both before and after notice of Federal funding; flexibility by the research team in study design; and strong support from institutional leadership for "self-learning health system" research.

Conclusions: By paying careful attention to identifying and collaborating with a wide range of key clinical stakeholders, we have shown that researchers embedded within a learning care system can successfully apply rigorous clinical trial methods to test new care innovations.
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http://dx.doi.org/10.1016/j.cct.2016.01.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4818191PMC
March 2016

Providers' Experiences with a Melanoma Web-Based Course: a Discussion on Barriers and Intentions.

J Cancer Educ 2017 Jun;32(2):272-279

Dermatoepidemiology Unit, Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA.

Primary care visits provide an opportunity for skin examinations with the potential to reduce melanoma mortality. The INFORMED (INternet curriculum FOR Melanoma Early Detection) Group developed a Web-based curriculum to improve primary care providers' (PCPs') skin cancer detection skills. This study details feedback obtained from participant focus groups, including the feasibility of implementing in other PCP practices. Practicing PCPs at Henry Ford Health System and Kaiser Permanente Northern California completed the curriculum. Feedback sessions were conducted with standardized questions focusing on four domains: (1) overall impressions of the curriculum, (2) recommendations for improvement, (3) current skin examination practices, and (4) suggestions for increasing skin screening by PCPs. Discussions at each site were audio recorded, transcribed verbatim, and de-identified. Providers (N = 54) had a positive impression of the Web-based curriculum, with suggestions to provide offline teaching aids and request assistance. Despite having improved confidence in diagnosing malignant lesions, many providers felt a lack of confidence in performing the screening and time constraints affected their current practices, as did institutional constraints. Providers intended to increase discussion with patients about skin cancer. The accessibility, effectiveness, and popularity of the curriculum indicate potential for implementation in the primary care setting. Participating providers noted that institutional barriers remain which must be addressed for successful dissemination and implementation.
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http://dx.doi.org/10.1007/s13187-015-0910-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4803637PMC
June 2017
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