Publications by authors named "Morris Weinberger"

208 Publications

Implementation of social needs screening in primary care: a qualitative study using the health equity implementation framework.

BMC Health Serv Res 2021 Sep 17;21(1):975. Epub 2021 Sep 17.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response.

Methods: Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis.

Results: Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach.

Conclusion: Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations.
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http://dx.doi.org/10.1186/s12913-021-06991-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8445654PMC
September 2021

Reducing Poverty-Related Disparities in Cervical Cancer: The Role of HPV Vaccination.

Cancer Epidemiol Biomarkers Prev 2021 Sep 9. Epub 2021 Sep 9.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Near elimination of cervical cancer in the United States is possible in coming decades, yet inequities will delay this achievement for some populations. We sought to explore the effects of human papillomavirus (HPV) vaccination on disparities in cervical cancer incidence between high- and low-poverty U.S. counties.

Methods: We calibrated a dynamic simulation model of HPV infection to reflect average counties in the highest and lowest quartile of poverty (percent of population below federal poverty level), incorporating data on HPV prevalence, cervical cancer screening, and HPV vaccination. We projected cervical cancer incidence through 2070, estimated absolute and relative disparities in incident cervical cancer for high- versus low-poverty counties, and compared incidence with the near-elimination target (4 cases/100,000 women annually).

Results: We estimated that, on average, low-poverty counties will achieve near-elimination targets 14 years earlier than high-poverty counties (2029 vs. 2043). Absolute disparities by county poverty will decrease, but relative differences are estimated to increase. We estimate 21,604 cumulative excess cervical cancer cases in high-poverty counties over the next 50 years. Increasing HPV vaccine coverage nationally to the Healthy People 2020 goal (80%) would reduce excess cancer cases, but not alter estimated time to reach the near-elimination threshold.

Conclusions: High-poverty U.S. counties will likely be delayed in achieving near-elimination targets for cervical cancer and as a result will experience thousands of potentially preventable cancers.

Impact: Alongside vaccination efforts, it is important to address the role of social determinants and health care access in driving persistent inequities by area poverty.
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http://dx.doi.org/10.1158/1055-9965.EPI-21-0307DOI Listing
September 2021

Adherence to Car Seat Tolerance Screening Differs by Indication and Patient Characteristics.

Matern Child Health J 2021 Aug 17. Epub 2021 Aug 17.

Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.

Objectives: To assess whether adherence to institutional car seat tolerance screening (CSTS) guidelines differed for infants born preterm (PTM), term low birth weight (T-LBW), or both preterm and low birth weight (P-LBW), and to examine the association between CSTS adherence and patient characteristics.

Study Design: Within two large academic and community hospitals, we retrospectively reviewed all infants meeting institutional criteria (< 37 weeks' gestation and/or < 2.27 kg) for CSTS from 2014 to 2018. Multivariable logistic regression evaluated the association of patient characteristics with institutional CSTS guideline adherence.

Results: 4374 eligible infants were born PTM (50.9%), T-LBW (6.5%), or P-LBW (42.6%). Adherence rates were 92.7% in the neonatal intensive care unit (NICU) and 95.2% in the well-baby nursery with initial CSTS failure rates of 6.1% and 9.9%, respectively. Adherence was lowest among T-LBW (80.7%) compared to PTM (95.1%) or P-LBW (92.2%) infants in the NICU (p < 0.001) and well-baby nursery (81.6%, 96.7% and 97.1%, respectively, p < 0.001). In bivariate analyses, gestational age, birth weight, insurance, race, hospital type, discharge year, and preferred language were associated with adherence. In fully-adjusted models, adherence was positively associated with lower gestational age, higher birth weight, non-Medicaid insurance, and later discharge year (NICU) and lower gestational age and later discharge year (well-baby nursery).

Conclusions: Adherence was lower for T-LBW than PTM or P-LBW infants, despite similar CSTS failure rates. Disparities in adherence among Medicaid-insured patients in the NICU warrant further study. Future studies are needed to clarify the benefit of CSTS and increase adherence in high-risk populations.
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http://dx.doi.org/10.1007/s10995-021-03220-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369874PMC
August 2021

Racial Residential Segregation and Race Differences in Ideal Cardiovascular Health among Young Men.

Int J Environ Res Public Health 2021 07 22;18(15). Epub 2021 Jul 22.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, SC 27599, USA.

Background: Race disparities in cardiovascular disease (CVD) related morbidity and mortality are evident among men. While previous studies show health in young adulthood and racial residential segregation (RRS) are important factors for CVD risk, these factors have not been widely studied in male populations. We sought to examine race differences in ideal cardiovascular health (CVH) among young men (ages 24-34) and whether RRS influenced this association.

Methods: We used cross-sectional data from young men who participated in Wave IV (2008) of the National Longitudinal Survey of Adolescent to Adult Health ( = 5080). The dichotomous outcome, achieving ideal CVH, was defined as having ≥4 of the American Heart Association's Life's Simple 7 targets. Race (Black/White) and RRS (proportion of White residents in census tract) were the independent variables. Descriptive and multivariate analyses were conducted.

Results: Young Black men had lower odds of achieving ideal CVH (OR = 0.67, 95% CI = 0.49, 0.92) than young White men. However, RRS did not have a significant effect on race differences in ideal CVH until the proportion of White residents was ≥55%.

Conclusions: Among young Black and White men, RRS is an important factor to consider when seeking to understand CVH and reduce future cardiovascular risk.
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http://dx.doi.org/10.3390/ijerph18157755DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8345482PMC
July 2021

Promoting Exercise and Healthy Diet Among Primary Care Patients: Feasibility, Preliminary Outcomes, and Lessons Learned From a Pilot Trial With High Intensity Interval Exercise.

Front Sports Act Living 2021 16;3:690243. Epub 2021 Jul 16.

Department of Exercise and Sport Science, Applied Physiology Laboratory, University of North Carolina, Chapel Hill, NC, United States.

Physical activity and healthy diet are recognized as effective approaches for disease prevention. Controlled laboratory clinical trials support these approaches, yet minimal data exists supporting implementation of exercise as medicine within a healthcare setting. To understand perception and barriers to exercise and nutrition from patients and physicians from a family medicine clinic (FMC) to inform the implementation of a laboratory-based exercise and nutrition lifestyle intervention (Phase I), and to determine the feasibility, adherence, and preliminary outcomes of implementing this lifestyle intervention into a FMC (Phase II). In phase I 10 patients and 5 physicians were interviewed regarding perceptions of exercise and nutrition practices. In phase II patients at risk for cardiovascular disease were enrolled into a lifestyle intervention ( = 16), within a FMC, manipulating diet and exercise. Cardiorespiratory fitness (CRF), body composition, and metabolic blood markers were completed at baseline, after the 12-week intervention, and at 24 weeks. Feasibility was defined by patients who completed the intervention and number of sessions vs. total available. Prescribing high-intensity interval training and a meal replacement for 12 weeks in patients with at least one risk factor for cardiovascular disease, was shown to have moderate feasibility with 62.5% ( = 10) for patients completing the 12 week intervention, and poor feasibility for assessing effects 12 weeks after cessation of the intervention, with 50% ( = 5) participants returning. Tracking exercise electronically via FitBit had moderate fidelity ( = 9), with hardcopy logs yielding poor compliance ( = 6). This pilot study demonstrated preliminary effectiveness of this home-based approach for improving cardiorespiratory fitness with an average 4.31 ± 5.67 ml·kg·min increase in peak oxygen consumption. Blood triglycerides and insulin were improved in 70% and 60% of the patients, respectively. Despite moderate feasibility, a home-based exercise and nutrition has the potential to be used as an effective approach for managing and mitigating cardiovascular disease risk factors. There were key lessons learned which will help to develop and adapt a larger scale lifestyle intervention into a clinical setting. https://clinicaltrials.gov/ct2/show/study/NCT02482922, identifier NCT02482922.
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http://dx.doi.org/10.3389/fspor.2021.690243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8322607PMC
July 2021

Evaluating the association of social needs assessment data with cardiometabolic health status in a federally qualified community health center patient population.

BMC Cardiovasc Disord 2021 07 14;21(1):342. Epub 2021 Jul 14.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr, Chapel Hill, NC, 27519, USA.

Background: Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients' clinical condition.

Methods: In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management.

Results: Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950).

Conclusions: Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance.
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http://dx.doi.org/10.1186/s12872-021-02149-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8278633PMC
July 2021

The Association of Readmission Reduction Activities with Primary Care Practice Readmission Rates.

J Gen Intern Med 2021 Jul 13. Epub 2021 Jul 13.

Department of Health Policy and Management, University of North Carolina Gillings School of Public Health, Chapel Hill, USA.

Background: A great deal of research has focused on how hospitals influence readmission rates. While hospitals play a vital role in reducing readmissions, a significant portion of the work also falls to primary care practices. Despite this critical role of primary care, little empirical evidence has shown what primary care characteristics or activities are associated with reductions in hospital admissions.

Objective: To examine the relationship between practices' readmission reduction activities and their readmission rates.

Design, Setting, And Participants: A retrospective study of 1,788 practices who responded to the National Survey of Healthcare Organizations and Systems (fielded 2017-2018) and 415,663 hospital admissions for Medicare beneficiaries attributed to those practices from 2016 100% Medicare claims data. We constructed mixed-effects logistic regression models to estimate practice-level readmission rates and a linear regression model to evaluate the association between practices' readmission rates with their number of readmission reduction activities.

Interventions: Standardized composite score, ranging from 0 to 1, representing the number of a practice's readmission reduction capabilities. The composite score was composed of 12 unique capabilities identified in the literature as being significantly associated with lower readmission rates (e.g., presence of care manager, medication reconciliation, shared-decision making, etc.).

Main Outcomes And Measures: Practices' readmission rates for attributed Medicare beneficiaries.

Key Results: Routinely engaging in more readmission reduction activities was significantly associated (P < .05) with lower readmission rates. On average, practices experienced a 0.05 percentage point decrease in readmission rates for each additional activity. Average risk-standardized readmission rates for practices performing 10 or more of the 12 activities in our composite measure were a full percentage point lower than risk-standardized readmission rates for practices engaging in none of the activities.

Conclusions: Primary care practices that engaged in more readmission reduction activities had lower readmission rates. These findings add to the growing body of evidence suggesting that engaging in multiple activities, rather than any single activity, is associated with decreased readmissions.
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http://dx.doi.org/10.1007/s11606-021-07005-yDOI Listing
July 2021

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis.

BMC Public Health 2021 07 12;21(1):1379. Epub 2021 Jul 12.

Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, USA.

Background: Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria.

Methods: This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics.

Results: Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores.

Conclusion: Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.
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http://dx.doi.org/10.1186/s12889-021-11436-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8274034PMC
July 2021

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

Reprod Health 2021 Feb 23;18(1):47. Epub 2021 Feb 23.

University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities.

Methods: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high).

Results: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high.

Conclusion: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.
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http://dx.doi.org/10.1186/s12978-021-01105-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903768PMC
February 2021

Travel time, availability of emergency obstetric care, and perceived quality of care associated with maternal healthcare utilisation in Afghanistan: A multilevel analysis.

Glob Public Health 2021 Jan 18:1-18. Epub 2021 Jan 18.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Limited understanding of factors such as travel time, availability of emergency obstetric care (EmOC), and satisfaction/perceived quality of care on the utilisation of maternal health services exists in fragile and conflict-affect settings. We examined these key factors on three utilisation outcomes: at least one skilled antenatal care (ANC) visit, in-facility delivery, and bypassing the nearest public facility for childbirth in Afghanistan from 2010 to 2015. We used three-level multilevel mixed effects logistic regression models to assess the relationships between women's and their nearest public facilities' characteristics and outcomes. The nearest facility score for satisfaction/perceived quality was associated with having at least one skilled ANC visit (AOR: 2.02, 95% CI: 1.21, 3.36). Women whose nearest facility provided EmOC had a higher odds of in-facility childbirth compared to women whose nearest facility did not (AOR: 1.24, 95% CI: 1.04, 1.48). Nearest hospital travel time (AOR: 0.95, 95% CI: 0.93, 0.98) and nearest facility satisfaction/perceived quality (AOR: 0.34, 95% CI: 0.14, 0.82) were associated with lower odds of women bypassing their nearest facility. Afghanistan has made progress in expanding access to maternal healthcare services during the ongoing conflict. Addressing key barriers is essential to ensure that women have access to life-saving services.
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http://dx.doi.org/10.1080/17441692.2021.1873400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8286269PMC
January 2021

Cost-effectiveness of Interventions to Increase HPV Vaccine Uptake.

Pediatrics 2020 12 16;146(6). Epub 2020 Nov 16.

Departments of Health Policy and Management and.

Objectives: We sought to prioritize interventions for increasing human papillomavirus (HPV) vaccination coverage based on cost-effectiveness from a US state perspective to inform decisions by policy makers.

Methods: We developed a dynamic simulation model of HPV transmission and progression scaled to a medium-sized US state (5 million individuals). We modeled outcomes over 50 years comparing no intervention to a one-year implementation of centralized reminder and recall for HPV vaccination, school-located HPV vaccination, or quality improvement (QI) visits to primary care clinics. We used probabilistic sensitivity analysis to assess a range of plausible outcomes associated with each intervention. Cost-effectiveness was evaluated relative to a conservative willingness-to-pay threshold; $50 000 per quality-adjusted life-year (QALY) .

Results: All interventions were cost-effective, relative to no intervention. QI visits had the lowest cost and cost per QALY gained ($1538 versus no intervention). Statewide implementation of centralized reminder and recall cost $28 289 per QALY gained versus QI visits. School-located vaccination had the highest cost but was cost-effective at $18 337 per QALY gained versus QI visits. Scaling to the US population, interventions could avert 3000 to 14 000 future HPV cancers. When varying intervention cost and impact over feasible ranges, interventions were typically preferred to no intervention, but cost-effectiveness varied between intervention strategies.

Conclusions: Three interventions for increasing HPV vaccine coverage were cost-effective and offered substantial health benefits. Policy makers seeking to increase HPV vaccination should, at minimum, dedicate additional funding for QI visits, which are consistently effective at low cost and may additionally consider more resource-intensive interventions (reminder and recall or school-located vaccination).
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http://dx.doi.org/10.1542/peds.2020-0395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786823PMC
December 2020

National and subnational estimates of coverage and travel time to emergency obstetric care in Afghanistan: Modeling of spatial accessibility.

Health Place 2020 11 1;66:102452. Epub 2020 Oct 1.

Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Electronic address:

In Afghanistan, the risk of maternal death is among the highest in the world, with wide variation across the country. One explanation may be wide geographic disparities in access and use of maternal health care services. This study describes the spatial distribution of public facilities providing maternal health care in Afghanistan, specifically emergency obstetric care (EmOC), and the differences in travel time estimates using different transportation modes from 2010 to 2015 at the national and subnational levels. We conducted mapping and spatial analyses to measure the proportion of pregnant women able to access any EmOC health facility within 2 h by foot, animal, motor vehicle and a combination of transport modes. In 2015, adequate coverage of active public health facilities within 2 h of travel time was 36.6% by foot and 71.2% by a combination of transport modes. We found an 8.3% and 63.2% increase in access to EmOC facilities within 2 h of travel time by a combination of transport modes and by foot only, respectively, by 2015. Access to a combination of transportation options such as motor vehicles and animals may benefit pregnant women in reaching health facilities efficiently. Afghanistan made impressive gains in maternal healthcare access; despite these improvements, large disparities remain in geographic access by province and overall access to facilities is still poor.
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http://dx.doi.org/10.1016/j.healthplace.2020.102452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773147PMC
November 2020

The association between the supply of select nonpharmacologic providers for pain and use of nonpharmacologic pain management services and initial opioid prescribing patterns for Medicare beneficiaries with persistent musculoskeletal pain.

Health Serv Res 2021 Apr 1;56(2):275-288. Epub 2020 Oct 1.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Oakland, California, USA.

Objective: To test the relationship between the supply of select nonpharmacologic providers (physical therapy (PT) and mental health (MH)) and use of nonpharmacologic services among older adults with a persistent musculoskeletal pain (MSP) episode.

Data Sources/study Setting: Claims data from a 5 percent random sample of Medicare beneficiaries enrolled fee-for-service (2007-2014) and the Area Health Resource File (AHRF).

Study Design: This retrospective study used generalized estimating equations to estimate the association between the county nonpharmacologic provider supply and individual service use with opioid prescriptions filled during Phase 1 (first three months of an episode) and Phase 2 (three months following Phase 1).

Data Collection/extraction Methods: We identified beneficiaries (>65 years) with ≥2 MSP diagnoses ≥90 days apart and no opioid prescription six months before the first pain diagnosis (N = 69 456). Beneficiaries' county characteristics were assigned using the AHRF.

Principal Findings: About 13.9 percent of beneficiaries used PT, 1.8 percent used MH services, and 10.7 percent had an opioid prescription during the first three months of a persistent MSP episode. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT/10 000 people/county [aOR: 0.98, 95% CI: 0.97-1.00] was associated with lower odds of filling an opioid prescription in Phase 1. An additional MH provider/10 000 people/county [aOR: 0.97, 95% CI: 0.96-0.98] and PT use in Phase 1 [aOR: 0.62, 95% CI: 0.58-0.67] were associated with lower odds of filling an opioid prescription in Phase 2. The associations between the supply of providers and nonpharmacologic service use in Phase 1 and Phase 1 opioid prescriptions significantly differed by metropolitan and rural counties (P-value: .019).

Conclusions: Limited access to nonpharmacologic services is associated with opioid prescriptions at the onset of a persistent MSP episode. Initiating PT at the onset of an episode may reduce future opioid use. Strategies for engaging beneficiaries in nonpharmacologic services should be tailored for metropolitan and rural counties.
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http://dx.doi.org/10.1111/1475-6773.13561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7969208PMC
April 2021

Impact of California's mandate for antimicrobial stewardship programs on rates of methicillin-resistant and infection in acute-care hospitals.

Infect Control Hosp Epidemiol 2021 03 1;42(3):298-304. Epub 2020 Oct 1.

Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

Objective: To estimate the impact of California's antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals.

Population: Centers for Medicare and Medicaid Services (CMS)-certified acute-care hospitals in the United States.

Data Sources: 2013-2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports.

Methods: Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate.

Results: In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017.

Conclusions: The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.
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http://dx.doi.org/10.1017/ice.2020.446DOI Listing
March 2021

Are Rates of Methicillin-Resistant Staphylococcus aureus and Clostridioides difficile Associated With Quality and Clinical Outcomes in US Acute Care Hospitals?

Am J Med Qual 2021 Mar-Apr 01;36(2):90-98

University of North Carolina, Chapel Hill, NC North Carolina Department of Health and Human Services, Raleigh, NC.

The purpose of this study was to examine the association between rates of methicillin-resistant Staphylococcus aureus (MRSA)/Clostridioides difficile and quality and clinical outcomes in US acute care hospitals. The population was all Medicare-certified US acute care hospitals with MRSA/C difficile standardized infection ratio (SIR) data available from 2013 to 2017. Hospital-level data from the Centers for Medicare & Medicaid Services were used to estimate hospital and time fixed effects models for 30-day hospital readmissions, length of stay, 30-day mortality, and days in the intensive care unit. The key explanatory variables were SIR for MRSA and C difficile. No association was found between MRSA or C difficile rates and any of the 4 outcomes. The null results add to the mixed evidence in the field, but there are likely residual confounding factors. Future research should use larger samples of patient-level data and appropriate methods to provide evidence to guide efforts to tackle antimicrobial resistance.
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http://dx.doi.org/10.1177/1062860620942310DOI Listing
July 2020

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial.

Trials 2020 Jul 6;21(1):615. Epub 2020 Jul 6.

Department of Psychology and Neuroscience, Duke University, Durham, NC, USA.

Background: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED).

Methods: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention.

Discussion: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies.

Trial Registration: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.
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http://dx.doi.org/10.1186/s13063-020-04552-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336469PMC
July 2020

Strategies for implementing best practices in independent physician associations.

Am J Manag Care 2020 06;26(6):262-266

Regal Medical Group, 8510 Balboa Blvd, Ste 150, Northridge, CA 91325. Email:

Objectives: Scholars have highlighted the importance of preventing hospital admissions and readmissions for individuals with costly chronic conditions. Providing effective care management strategies can help reduce inpatient admissions, thereby reducing rising health care costs. However, implementing effective care management strategies may be more difficult for independent physician associations (IPAs) that contract with multiple organizations that have competing interests and agendas. This study aims to identify and investigate strategies that facilitate the implementation of evidence-based best practices among IPAs.

Study Design: The research synthesized peer-reviewed literature to identify best practices in chronic disease management for Medicare beneficiaries. Subsequently, 20 key informant interviews were conducted to explore barriers and facilitators in adapting these best practices in IPA settings. Informant interviews were conducted with 3 key groups: executives, medical directors, and care managers.

Methods: Key informant interviews were conducted to explore barriers and facilitators in implementing best care management practices.

Results: Key informants provided unique insights regarding the challenges of implementing best care management practices among IPAs. These challenges included implementing and sustaining the operations of evidence-based care management programs while maintaining contractual obligations to health plans, engaging physicians in large and diverse networks, and building high-touch programs in large geographic areas using risk-stratifying algorithms.

Conclusions: IPA managed care organizations require unique considerations in regard to selected strategies used to manage chronic disease in Medicare populations. These considerations are critical for optimal management of the population, particularly in a risk-based or pay-for-performance environment.
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http://dx.doi.org/10.37765/ajmc.2020.43489DOI Listing
June 2020

Improving the implementation and sustainment of evidence-based practices in community mental health organizations: a study protocol for a matched-pair cluster randomized pilot study of the Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS).

Implement Sci Commun 2020 25;1. Epub 2020 Feb 25.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Implementing and sustaining evidence-based programs with fidelity may require multiple implementation strategies tailored to address multi-level, context-specific barriers and facilitators. Ideally, selecting and tailoring implementation strategies should be guided by theory, evidence, and input from relevant stakeholders; however, methods to guide the selection and tailoring of strategies are not well-developed. There is a need for more rigorous methods for assessing and prioritizing implementation determinants (barriers and facilitators) and linking implementation strategies to determinants. The Collaborative Organizational Approach to Selecting and Tailoring Implementation Strategies (COAST-IS) is an intervention designed to increase the effectiveness of evidence-based practice implementation and sustainment. COAST-IS will enable organizational leaders and clinicians to use Intervention Mapping to select and tailor implementation strategies to address their site-specific needs. Intervention Mapping is a multi-step process that incorporates theory, evidence, and stakeholder perspectives to ensure that implementation strategies effectively address key determinants of change.

Methods: COAST-IS will be piloted with community mental health organizations that are working to address the needs of children and youth who experience trauma-related emotional or behavioral difficulties by engaging in a learning collaborative to implement an evidence-based psychosocial intervention (trauma-focused cognitive behavioral therapy). Organizations will be matched and then randomized to participate in the learning collaborative only (control) or to receive additional support through COAST-IS. The primary aims of this study are to (1) assess the acceptability, appropriateness, feasibility, and perceived utility of COAST-IS; (2) evaluate the organizational stakeholders' fidelity to the core elements of COAST-IS; and (3) demonstrate the feasibility of testing COAST-IS in a larger effectiveness trial.

Discussion: COAST-IS is a systematic method that integrates theory, evidence, and stakeholder perspectives to improve the effectiveness and precision of implementation strategies. If effective, COAST-IS has the potential to improve the implementation and sustainment of a wide range of evidence-based practices in mental health and other sectors.

Trial Registration: This study was registered in ClinicalTrials.gov (NCT03799432) on January 10, 2019 (last updated August 5, 2019).
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http://dx.doi.org/10.1186/s43058-020-00009-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7207049PMC
February 2020

Effect of the Patient-Centered Medical Home on Racial Disparities in Quality of Care.

J Gen Intern Med 2020 08 24;35(8):2304-2313. Epub 2020 Feb 24.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Research demonstrates that the patient-centered medical home (PCMH) is associated with improved clinical outcomes and quality of care, and the populations that can most benefit from this model require long-term management, e.g., persons with chronic illness and behavioral health conditions. However, different populations may not benefit equally from the PCMH, and empirical evidence about the effects of this model on racial disparities is limited.

Objective: Estimate the association between enrollment in National Committee for Quality Assurance (NCQA)-recognized PCMHs and racial disparities in quality of care for adults with major depressive disorder (MDD) and comorbid medical conditions.

Design: Applying a quasi-experimental instrumental variable design to account for differential selection into the PCMH, we used generalized estimating equations to determine the probability of receiving eight disease-specific quality measures.

Subjects: Medicaid enrollees in three states not dually enrolled in Medicare, ages 18-64 with MDD and > 1 other chronic condition. A subgroup analysis was conducted for enrollees with comorbid diabetes.

Interventions: Enrollment in an NCQA-recognized PCMH.

Main Measures: Disease-specific quality indicators for MDD (e.g., antidepressant use, receipt of psychotherapy), and for diabetes, (e.g. A1c testing, LDL-C testing, retinal exams, and medical attention for nephropathy).

Key Results: PCMH enrollment was associated with an increase in the overall likelihood of receiving six of eight recommended services and a decrease in the likelihood of receiving any psychotherapy (4.94 percentage points, p < 0.01) and retinal exams (5.51 percentage points, p < 0.05). Although both groups improved, PCMH enrollment was associated with an exacerbation of the Black-white disparity in adequate antidepressant use by 4.20 percentage points (p < 0.01).

Conclusions: While PCMH enrollment may improve the overall quality of care, the effect is inconsistent across racial groups and not always associated with reductions in racial disparities in quality.
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http://dx.doi.org/10.1007/s11606-020-05729-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403275PMC
August 2020

The Association Between the Supply of Nonpharmacologic Providers, Use of Nonpharmacologic Pain Treatments, and High-risk Opioid Prescription Patterns Among Medicare Beneficiaries With Persistent Musculoskeletal Pain.

Med Care 2020 05;58(5):433-444

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill.

Background: Opioids are prescribed more frequently than nonpharmacologic treatments for persistent musculoskeletal pain (MSP). We estimate the association between the supply of physical therapy (PT) and mental health (MH) providers and early nonpharmacologic service use with high-risk opioid prescriptions among Medicare beneficiaries with persistent MSP.

Research Design: We retrospectively studied Medicare beneficiaries (>65 y) enrolled in Fee-for-Service and Part D (2007-2014) with a new persistent MSP episode and no opioid prescription during the prior 6 months. Independent variables were nonpharmacologic provider supply per capita and early nonpharmacologic service use (any use during first 3 mo). One year outcomes were long-term opioid use (LTOU) (≥90 days' supply) and high daily dose (HDD) (≥50 mg morphine equivalent). We used multinomial regression and generalized estimating equations and present adjusted odds ratios (aORs).

Results: About 2.4% of beneficiaries had LTOU; 11.9% had HDD. The supply of MH providers was not associated with LTOU and HDD. Each additional PT/10,000 people/county was associated with greater odds of LTOU [aOR: 1.06; 95% confidence interval (CI), 1.01-1.11). Early MH use was associated with lower odds of a low-risk opioid use (aOR: 0.81; 95% CI, 0.68-0.96), but greater odds of LTOU (aOR: 1.93; 95% CI, 1.28-2.90). Among beneficiaries with an opioid prescription, early PT was associated with lower odds of LTOU (aOR: 0.75; 95% CI, 0.64-0.89), but greater odds of HDD (aOR: 1.25; 95% CI, 1.15-1.36).

Conclusions: The benefits of nonpharmacologic services on opioid use may be limited. Research on effective delivery of nonpharmacologic services to reduce high-risk opioid use for older adults with MSP is needed.
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http://dx.doi.org/10.1097/MLR.0000000000001299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451631PMC
May 2020

Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant bacteremia and infection in the United States.

Infect Control Hosp Epidemiol 2020 04 20;41(4):430-437. Epub 2019 Dec 20.

Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.

Objective: To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates.

Participants: All US states.

Design: Observational longitudinal study.

Methods: We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state.

Results: The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections.

Conclusions: Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.
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http://dx.doi.org/10.1017/ice.2019.352DOI Listing
April 2020

Does Receipt of Recommended Elements of Palliative Care Precede In-Hospital Death or Hospice Referral?

J Pain Symptom Manage 2020 04 10;59(4):778-786. Epub 2019 Dec 10.

Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA.

Context: Palliative care aligns treatments with patients' values and improves quality of life, yet whether receipt of recommended elements of palliative care is associated with end-of-life outcomes is understudied.

Objectives: To assess whether recommended elements of palliative care (pain and symptom management, goals of care, and spiritual care) precede in-hospital death and hospice referral and whether delivery by specialty palliative care affects that relationship.

Methods: We conducted structured chart reviews for decedents with late-stage cancer, dementia, and chronic kidney disease with a hospital admission during the six months preceding death. Measures included receipt of recommended elements of palliative care delivered by any clinician and specialty palliative care consult. We assessed associations between recommended elements of palliative care and in-hospital death and hospice referral using multivariable Poisson regression models.

Results: Of 402 decedents, 67 (16.7%) died in hospital, and 168 (41.8%) had hospice referral. Among elements of palliative care, only goals-of-care discussion was associated with in-hospital death (incidence rate ratio [IRR] 1.37; 95% CI 1.01-1.84) and hospice referral (IRR 1.85; 95% CI 1.31-2.61). Specialty palliative care consult was associated with a lower likelihood of in-hospital death (IRR 0.57; 95% CI 0.44-0.73) and a higher likelihood of hospice referral (IRR 1.45; 95% CI 1.12-1.89) compared with no consult.

Conclusion: Goals-of-care discussions by different types of clinicians commonly precede end-of-life care in hospital or hospice. However, engagement with specialty palliative care reduced in-hospital death and increased hospice referral. Understanding the causal pathways of goals-of-care discussions may help build primary palliative care interventions to support patients near the end of life.
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http://dx.doi.org/10.1016/j.jpainsymman.2019.11.011DOI Listing
April 2020

A case study of a theory-based method for identifying and reporting core functions and forms of evidence-based interventions.

Transl Behav Med 2021 02;11(1):21-33

Department of Health Policy and Management, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Adaptation of existing evidence-based interventions (EBIs) to improve their fit in new contexts is common. A critical first step in adaptation is to identify core functions (purposes) and forms (activities) of EBIs. Core functions should not be adapted as they are what account for the efficacy of EBIs. Despite their importance, core functions are rarely identified by EBI developers; methods for identifying them post hoc are lacking. We present a case study of theory-based methods for identifying core functions and forms post hoc. We developed these methods as the first step in a larger effort to adapt an existing EBI to improve the timeliness of referrals to hospice to a new patient population and care setting. Our methods were rooted in the Planned Adaptation Model (PAM). Through our case study, we developed six steps for identifying core functions and forms, as well as accompanying tools and methods. Our case study further operationalized PAM in several ways. Where PAM offered guiding tenets for identifying core functions and forms (review existing EBI materials, conduct primary data collection, and identify the theory of change), we produced specific tools (interview guides and codebooks) and methods (sampling approaches and analytic methods). Our case study extended PAM with the addition of two steps in the process of identifying core functions and forms: (a) identifying the usual care pathway, including barriers to the outcome of interest encountered in usual care, and (b) mapping EBI core functions onto an extant theory. Identifying core functions and forms is a critical first step in the adaptation process to ensure adaptations do not inadvertently compromise the efficacy or effectiveness of the EBI by compromising core functions. Our case study presents step-by-step methods that could be used by researchers or practitioners to identify core functions and forms post hoc.
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http://dx.doi.org/10.1093/tbm/ibz178DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877297PMC
February 2021

Elements of Palliative Care in the Last 6 Months of Life: Frequency, Predictors, and Timing.

J Gen Intern Med 2020 03 24;35(3):753-761. Epub 2019 Oct 24.

Department of Health Policy and Management, University of North Carolina, Chapel Hill, NC, USA.

Importance: Persons living with serious illness often need skilled symptom management, communication, and spiritual support. Palliative care addresses these needs and may be delivered by either specialists or clinicians trained in other fields. It is important to understand core elements of palliative care to best provide patient-centered care.

Objective: To describe frequency, predictors, and timing of core elements of palliative care during the last 6 months of life.

Design: Retrospective chart review.

Setting: Inpatient academic medical center.

Participants: Decedents with cancer, dementia, or chronic kidney disease (CKD) admitted during the 6 months preceding death.

Exposures: We identified receipt and timing of core elements of palliative care: pain and symptom management, goals of care, spiritual care; and specialty palliative care utilization; hospital encounters; demographics; and comorbid diagnoses. We ran Poisson regression models to assess whether diagnosis or hospital encounters were associated with core elements of palliative care.

Results: Among 402 decedents, the mean (SD) number of appropriately screened and treated symptoms was 2.9 (1.7)/10. Among 76.1% with documented goals of care, 58.0% had a primary goal of comfort; 55.0% had documented spiritual care. In multivariable models, compared with decedents with cancer, those with dementia or CKD were less likely to have pain and symptom management (respectively, 31% (incidence rate ratio [IRR], 0.69; 95% CI, 0.56-0.85) and 17% (IRR, 0.83; CI, 0.71-0.97)). There was a median of 3 days (IQR, 0-173) between transition to a goal of comfort and death, and a median of 12 days (IQR, 5-47) between hospice referral and death.

Conclusions And Relevance: Although a high proportion of patients received elements of palliative care, transitions to a goal of comfort or hospice happened very near death. Palliative care delivery can be improved by systematizing existing mechanisms, including prompts for earlier goals-of-care discussion, symptom screening, and spiritual care, and by building collaboration between primary and specialty palliative care services.
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http://dx.doi.org/10.1007/s11606-019-05349-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080876PMC
March 2020

Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial.

J Gen Intern Med 2020 01 5;35(1):79-86. Epub 2019 Sep 5.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, HSR&D, Fulton Street, Durham, NC, USA.

Background: Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit.

Objective: To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED.

Design: Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976).

Setting: Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC.

Participants: Five hundred thirteen Veterans who were at high risk for repeat ED visits.

Intervention: The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services.

Main Measures: The primary outcome was repeat ED use within 30 days.

Key Results: Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care.

Conclusions: A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services.

Trials Registration: ClinicalTrials.gov NCT01717976.
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http://dx.doi.org/10.1007/s11606-019-05319-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6957582PMC
January 2020

The Medicare Shared Savings Program and Outcomes for Ischemic Stroke Patients: a Retrospective Cohort Study.

J Gen Intern Med 2019 12 26;34(12):2740-2748. Epub 2019 Aug 26.

Duke Clinical Research Institute, Durham, NC, USA.

Background: Post-stroke care delivery may be affected by provider participation in Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) through systematic changes to discharge planning, care coordination, and transitional care.

Objective: To evaluate the association of MSSP with patient outcomes in the year following hospitalization for ischemic stroke.

Design: Retrospective cohort SETTING: Get With The Guidelines (GWTG)-Stroke (2010-2014) PARTICIPANTS: Hospitalizations for mild to moderate incident ischemic stroke were linked with Medicare claims for fee-for-service beneficiaries ≥ 65 years (N = 251,605).

Main Measures: Outcomes included discharge to home, 30-day all-cause readmission, length of index hospital stay, days in the community (home-time) at 1 year, and 1-year recurrent stroke and mortality. A difference-in-differences design was used to compare outcomes before and after hospital MSSP implementation for patients (1) discharged from hospitals that chose to participate versus not participate in MSSP or (2) assigned to an MSSP ACO versus not or both. Unique estimates for 2013 and 2014 ACOs were generated.

Key Results: For hospitals joining MSSP in 2013 or 2014, the probability of discharge to home decreased by 2.57 (95% confidence intervals (CI) = - 4.43, - 0.71) percentage points (pp) and 1.84 pp (CI = - 3.31, - 0.37), respectively, among beneficiaries not assigned to an MSSP ACO. Among discharges from hospitals joining MSSP in 2013, beneficiary ACO alignment versus not was associated with increased home discharge, reduced length of stay, and increased home-time. For patients discharged from hospitals joining MSSP in 2014, ACO alignment was not associated with changes in utilization. No association between MSSP and recurrent stroke or mortality was observed.

Conclusions: Among patients with mild to moderate ischemic stroke, meaningful reductions in acute care utilization were observed only for ACO-aligned beneficiaries who were also discharged from a hospital initiating MSSP in 2013. Only 1 year of data was available for the 2014 MSSP cohort, and these early results suggest further study is warranted.

Registration: None.
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http://dx.doi.org/10.1007/s11606-019-05283-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854149PMC
December 2019

Cardiovascular disease-related chronic conditions among Veterans Affairs nonmetastatic colorectal cancer survivors: a matched case-control analysis.

Cancer Manag Res 2019 22;11:6793-6802. Epub 2019 Jul 22.

Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Purpose: The growing number of colorectal cancer (CRC) survivors often have multiple chronic conditions. Comparing nonmetastatic CRC survivors and matched noncancer controls, our objectives were to determine the odds of CRC survivors being diagnosed with cardiovascular disease (CVD)-related chronic conditions and their likelihood of control during the year after CRC diagnosis.

Patients And Methods: We retrospectively identified patients diagnosed with nonmetastatic CRC in the Veterans Affairs health care system from fiscal years 2009 to 2012 and matched each with up to 3 noncancer control patients. We used logistic regression to assess differences in the likelihood of being diagnosed with CVD-related chronic conditions and control between nonmetastatic CRC survivors and noncancer controls.

Results: We identified 9,758 nonmetastatic CRC patients and matched them to 29,066 noncancer controls. At baseline, 69.4% of CRC survivors and their matched controls were diagnosed with hypertension, 52.4% with hyperlipidemia, and 36.7% with diabetes. Compared to matched noncancer controls, CRC survivors had 57% higher odds of being diagnosed with hypertension (OR=1.57, 95% CI=1.49-1.64) and 7% higher odds of controlled blood pressure (OR=1.07, 95% CI 1.02, 1.13) in the subsequent year. Compared to matched noncancer control patients, CRC survivors had half the odds of being diagnosed with hyperlipidemia (OR=0.50, 95% CI=0.48-0.52) and lower odds of low-density lipoprotein (LDL) control (OR 0.88, 95% CI 0.81-0.94). There were no significant differences between groups for diabetes diagnoses or control.

Conclusion: Compared to noncancer controls, nonmetastatic CRC survivors have 1) greater likelihood of being diagnosed with hypertension and worse blood pressure control in the year following diagnosis; 2) lower likelihood of being diagnosed with hyperlipidemia or LDL control; and 3) comparable diabetes diagnoses and control. There may be a need for hypertension control interventions targeting cancer survivors.
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http://dx.doi.org/10.2147/CMAR.S191040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6659791PMC
July 2019

Electronic Health Record Phenotypes for Identifying Patients with Late-Stage Disease: a Method for Research and Clinical Application.

J Gen Intern Med 2019 12 8;34(12):2818-2823. Epub 2019 Aug 8.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.

Background: Systematic identification of patients allows researchers and clinicians to test new models of care delivery. EHR phenotypes-structured algorithms based on clinical indicators from EHRs-can aid in such identification.

Objective: To develop EHR phenotypes to identify decedents with stage 4 solid-tumor cancer or stage 4-5 chronic kidney disease (CKD).

Design: We developed two EHR phenotypes. Each phenotype included International Classification of Diseases (ICD)-9 and ICD-10 codes. We used natural language processing (NLP) to further specify stage 4 cancer, and lab values for CKD.

Subjects: Decedents with cancer or CKD who had been admitted to an academic medical center in the last 6 months of life and died August 26, 2017-December 31, 2017.

Main Measure: We calculated positive predictive values (PPV), false discovery rates (FDR), false negative rates (FNR), and sensitivity. Phenotypes were validated by a comparison with manual chart review. We also compared the EHR phenotype results to those admitted to the oncology and nephrology inpatient services.

Key Results: The EHR phenotypes identified 271 decedents with cancer, of whom 186 had stage 4 disease; of 192 decedents with CKD, 89 had stage 4-5 disease. The EHR phenotype for stage 4 cancer had a PPV of 68.6%, FDR of 31.4%, FNR of 0.5%, and 99.5% sensitivity. The EHR phenotype for stage 4-5 CKD had a PPV of 46.4%, FDR of 53.7%, FNR of 0.0%, and 100% sensitivity.

Conclusions: EHR phenotypes efficiently identified patients who died with late-stage cancer or CKD. Future EHR phenotypes can prioritize specificity over sensitivity, and incorporate stratification of high- and low-palliative care need. EHR phenotypes are a promising method for identifying patients for research and clinical purposes, including equitable distribution of specialty palliative care.
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http://dx.doi.org/10.1007/s11606-019-05219-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6854193PMC
December 2019

Family Caregiver Skills Training to Improve Experiences of Care: a Randomized Clinical Trial.

J Gen Intern Med 2019 10 6;34(10):2114-2122. Epub 2019 Aug 6.

Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 1101A McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill, NC, 27599, USA.

Objective: To evaluate the effectiveness of Helping Invested Families Improve Veterans' Experiences Study (HI-FIVES), a skills training program for caregivers of persons with functional or cognitive impairments.

Design: A two-arm RCT.

Setting: Single Veterans Affairs Medical Center.

Participants: Patients and their primary caregivers referred in the past 6 months to home and community-based services or geriatrics clinic.

Intervention: All caregivers received usual care. Caregivers in HI-FIVES also received five training calls and four group training sessions.

Main Measures: Cumulative patient days at home 12 months post-randomization, defined as days not in an emergency department, inpatient hospital, or post-acute facility. Secondary outcomes included patients' total VA health care costs, caregiver and patient rating of the patient's experience of VA health care, and caregiver depressive symptoms.

Results: Of 241 dyads, caregivers' (patients') mean age was 61 (73) years, 54% (53%) Black and 89% (4%) female. HI-FIVES was associated with a not statistically significant 9% increase in the rate of days at home (95% CI 0.72, 1.65; mean difference 1 day over 12 months). No significant differences were observed in health care costs or caregiver depressive symptoms. Model-estimated mean baseline patient experience of VA care (scale of 0-10) was 8.43 (95% CI 8.16, 8.70); the modeled mean difference between HI-FIVES and controls at 3 months was 0.29 (p = .27), 0.31 (p = 0.26) at 6 months, and 0.48 (p = 0.03) at 12 months. For caregivers, it was 8.34 (95% CI 8.10, 8.57); the modeled mean difference at 3 months was 0.28 (p = .18), 0.53 (p < .01) at 6 months, and 0.46 (p = 0.054) at 12 months.

Conclusions: HI-FIVES did not increase patients' days at home; it showed sustained improvements in caregivers' and patients' experience of VA care at clinically significant levels, nearly 0.5 points. The training holds promise in increasing an important metric of care quality-reported experience with care.
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http://dx.doi.org/10.1007/s11606-019-05209-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6816649PMC
October 2019

Nonpharmacological Self-Management of Migraine Across Social Locations: An Equity-Oriented, Qualitative Analysis.

Glob Adv Health Med 2019 13;8:2164956119858034. Epub 2019 Jun 13.

Department of Family and Community Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina.

Background: Migraine is a disabling neurological disorder and the sixth biggest cause of disability worldwide. The World Health Organization has declared migraine a major public health problem due to a paucity of knowledge about cause and effective treatment options. Both in incidence and severity, migraine disproportionately affects people occupying marginalized social locations (SL). Managed pharmacologically, migraine is treated with daily preventive and as-needed abortive medications. Both come with high literal and figurative costs: intolerable side effects, medication interactions, and prohibitive prices. Cost prohibitive, ineffective, and unsustainable pharmacological treatment options have contributed to high levels of interest in complementary approaches by people with migraine, but little is known about their motivations, patterns of use or access, or how these may vary by SL.

Method: We conducted focus groups with 30 people with migraine to explore their desires and recommendations for migraine clinicians and researchers. We used qualitative content analysis to identify themes.Outcomes: We identified 4 themes: a more holistic, collaborative, long-term treatment approach; medication as a short-term solution; high personal and economic costs of medication; and desire for more information and access to natural approaches. Across SL, participants expressed keen interest in integrative approaches and wanted better access to complementary modalities. Participants in marginalized SL described reliance on traditional/folk remedies, including engagement with family and community healers, who they described as more affordable and culturally accessible.

Conclusions: Holistic and integrative approaches were preferred over medication as long-term migraine management strategies. However, people in marginalized SL, while disproportionately disabled by migraine, did not feel as comfortable accessing integrative approaches through currently available channels. Engaging with these communities and using a critical lens to explore barriers to access can develop options to make complementary modalities more approachable, while also attending to systemic blind spots that may unintentionally alienate socially marginalized groups.
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http://dx.doi.org/10.1177/2164956119858034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6566474PMC
June 2019
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