Publications by authors named "Virginia Wang"

54 Publications

Unintended consequences of COVID-19 social distancing among older adults with kidney disease.

J Gerontol A Biol Sci Med Sci 2021 Jul 21. Epub 2021 Jul 21.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC.

Background: While social distancing policies protect older adults with advanced chronic kidney disease (CKD) from exposure to COVID-19, reduced social interaction may also have unintended consequences.

Methods: To identify subgroups of patients at risk for unintended health consequences of social distancing, we conducted a cross-sectional analysis of data from a national cohort study of older Veterans with advanced CKD (n=223). Characteristics included activities of daily living (ADLs), instrumental ADLs (IADLs), cognition score, depression score, social support, financial stress, symptom burden, and number of chronic conditions. Unintended consequences of social distancing included restricted Life Space mobility, low willingness for video telehealth, reduced in-person contact with caregivers, and food insecurity. We identified subgroups of patients at risk of unintended consequences using model-based recursive partitioning (MoB).

Results: Participants had a mean age of 77.9 years, 64.6% were white, and 96.9% were male. Overall, 22.4% of participants had restricted Life Space, 33.9% reported low willingness for video telehealth, 19.0% reported reduced caregiver contact, and 3.2% reported food insecurity. For Life Space restriction, four subgroups partitioned (i.e., split) by IADL difficulty, cognition score, and ADL difficulty were identified. The highest rate of restricted Life Space was 54.7% in the subgroup of participants with >3 IADL difficulties For low willingness for telehealth and reduced caregiver contact, separate models identified two subgroups split by cognition score and depression score, respectively.

Conclusions: Measures of function, cognition, and depressive symptoms may identify older adults with advanced CKD who are at higher risk for unintended health consequences of social distancing.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/gerona/glab211DOI Listing
July 2021

Annual wellness visits and care management before and after dialysis initiation.

BMC Nephrol 2021 May 5;22(1):164. Epub 2021 May 5.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Introduction: Demands of dialysis regimens may pose challenges for primary care provider (PCP) engagement and timely preventive care. This is especially the case for patients initiating dialysis adjusting to new logistical challenges and management of symptoms and existing comorbid conditions. Since 2011, Medicare has provided coverage for annual wellness visits (AWV), which are primarily conducted by PCPs and may be useful for older adults undergoing dialysis.

Methods: We used the OptumLabs® Data Warehouse to identify a cohort of 1,794 Medicare Advantage (MA) enrollees initiating dialysis in 2014-2017 and examined whether MA enrollees (1) were seen by a PCP during an outpatient visit and (2) received an AWV in the year following dialysis initiation.

Results: In the year after initiating dialysis, 93 % of MA enrollees had an outpatient PCP visit but only 24 % received an annual wellness visit. MA enrollees were less likely to see a PCP if they had Charlson comorbidity scores between 0 and 5 than those with scores 6-9 (odds ratio (OR) = 0.59, 95 % CI: 0.37-0.95), but more likely if seen by a nephrologist (OR = 1.60, 95 % CI: 1.01-2.52) or a PCP (OR = 15.65, 95 % CI: 9.26-26.46) prior to initiation. Following dialysis initiation, 24 % of MA enrollees had an AWV. Hispanic MA enrollees were less likely (OR = 0.57, 95 % CI: 0.39-0.84) to have an AWV than White MA enrollees, but enrollees were more likely if they initiated peritoneal dialysis (OR = 1.54, 95 % CI: 1.07-2.23) or had an AWV in the year before dialysis initiation (OR = 4.96, 95 % CI: 3.88-6.34).

Conclusions: AWVs are provided at low rates to MA enrollees initiating dialysis, particularly Hispanic enrollees, and represent a missed opportunity for better care management for patients with ESKD. Increasing patient awareness and provider provision of AWV use among dialysis patients may be needed, to realize better preventive care for dialysis patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12882-021-02368-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8097997PMC
May 2021

Source of Post-Transplant Care and Mortality among Kidney Transplant Recipients Dually Enrolled in VA and Medicare.

Clin J Am Soc Nephrol 2021 03 18;16(3):437-445. Epub 2021 Feb 18.

Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Background And Objectives: Many kidney transplant recipients enrolled in the Veterans Health Administration are also enrolled in Medicare and eligible to receive both Veterans Health Administration and private sector care. Where these patients receive transplant care and its association with mortality are unknown.

Design, Setting, Participants, & Measurements: We conducted a retrospective cohort study of veterans who underwent kidney transplantation between 2008 and 2016 and were dually enrolled in Veterans Health Administration and Medicare at the time of surgery. We categorized patients on the basis of the source of transplant-related care (., outpatient transplant visits, immunosuppressive medication prescriptions, calcineurin inhibitor measurements) delivered during the first year after transplantation defined as Veterans Health Administration only, Medicare only (., outside Veterans Health Administration using Medicare), or dual care (mixed use of Veterans Health Administration and Medicare). Using multivariable Cox regression, we examined the independent association of post-transplant care source with mortality at 5 years after kidney transplantation.

Results: Among 6206 dually enrolled veterans, 975 (16%) underwent transplantation at a Veterans Health Administration hospital and 5231 (84%) at a non-Veterans Health Administration hospital using Medicare. Post-transplant care was received by 752 patients (12%) through Veterans Health Administration only, 2092 (34%) through Medicare only, and 3362 (54%) through dual care. Compared with patients who were Veterans Health Administration only, 5-year mortality was significantly higher among patients who were Medicare only (adjusted hazard ratio, 2.2; 95% confidence interval, 1.5 to 3.1) and patients who were dual care (adjusted hazard ratio, 1.5; 95% confidence interval, 1.1 to 2.1).

Conclusions: Most dually enrolled veterans underwent transplantation at a non-Veterans Health Administration transplant center using Medicare, yet many relied on Veterans Health Administration for some or all of their post-transplant care. Veterans who received Veterans Health Administration-only post-transplant care had the lowest 5-year mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.10020620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011004PMC
March 2021

Facility-Level Variation in Dialysis Use and Mortality Among Older Veterans With Incident Kidney Failure.

JAMA Netw Open 2021 01 4;4(1):e2034084. Epub 2021 Jan 4.

Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.

Importance: Current guidelines lack consensus regarding the treatment of patients who may not benefit from dialysis; this lack of consensus may be associated with the substantial variation in dialysis use and outcomes across health care facilities.

Objective: To assess the degree to which variation in dialysis use and mortality was associated with patient rather than facility characteristics and to distinguish which features identified the US Department of Veterans Affairs (VA) facilities with high rates of dialysis use.

Design, Setting, And Participants: This cohort study analyzed data of veterans with stage 3 or 4 chronic kidney disease that progressed to kidney failure between January 1, 2011, and December 31, 2014. These patients received care from VA facilities across the US. Data sources included laboratory and administrative records from the VA, Medicare, and United States Renal Data System. Data analysis was conducted from August 1, 2019, to September 1, 2020.

Exposures: The primary exposure was the VA facility in which patients received most of their care before the onset of incident kidney failure defined as the first occurrence of either a sustained estimated glomerular filtration rate of less than 15 mL/min/1.73 m2 or the initiation of maintenance dialysis.

Main Outcomes And Measures: The primary outcomes were dialysis use and mortality within 2 years of incident kidney failure. Median rate ratio was used to quantify facility-level variation, and variance partition coefficient was used to quantify the sources of unexplained variation.

Results: The cohort included 8695 older veterans with a mean (SD) age of 78.8 (7.5) years who were predominantly male (8573 [99%]) and White (6102 [70%]) individuals treated at 108 VA facilities. The observed frequency of dialysis use across facilities ranged from 25.0% to 81.4%, with a median (interquartile range [IQR]) rate of 51.7% (48.4%-60.0%). The observed frequency of mortality across facilities ranged from 27.2% to 60.0%, with a median (IQR) rate of 45.2% (41.2%-48.6%). The median rate ratio (adjusted for multiple patient and facility characteristics) was 1.40 for dialysis use and 1.08 for mortality. The unexplained variation in both outcomes mainly derived from patient characteristics rather than facility characteristics. No correlation was found between dialysis use and mortality at the facility level (correlation coefficient = 0.03).

Conclusions And Relevance: This study found sizable variation in dialysis use for older adults that was poorly correlated with facility-level mortality rates and was not accounted for by differences in measured patient and facility characteristics. These findings suggest opportunities to improve the degree to which dialysis use practices align with the values, goals, and preferences of older adults with kidney failure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2020.34084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811178PMC
January 2021

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

Med Care 2021 02;59(2):155-162

Departments of Population Health Sciences.

Background: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013.

Research Design: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics.

Results: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33).

Conclusions: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MLR.0000000000001457DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855236PMC
February 2021

Opioid Prescribing in the 2016 Medicare Fee-for-Service Population.

J Am Geriatr Soc 2021 Feb 20;69(2):485-493. Epub 2020 Nov 20.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.

Background And Objectives: Opioid use and misuse are prevalent and remain a national crisis. This study identified beneficiary characteristics associated with filling opioid prescriptions, variation in opioid dosing, and opioid use with average daily doses (ADDs) equal to 120 morphine milligram equivalents (MMEs) or more in the 100% Medicare fee-for-service (FFS) population.

Design, Setting, Participants, And Measurements: In a cohort of FFS beneficiaries with 12 months of Medicare Part D coverage in 2016, we examined patient factors associated with filling an opioid prescription (n = 20,880,490) and variation in ADDs (n = 7,325,031) in a two-part model. Among those filling opioids, we also examined the probability of ADD equal to 120 MMEs or more via logistic regression.

Results: About 35% of FFS beneficiaries had one or more opioid prescription fills in 2016 and 1.5% had ADDs equal to 120 MMEs or more. Disability-eligible beneficiaries and beneficiaries with multiple chronic conditions were more likely to fill opioids, to have higher ADDs or were more likely to have ADD equal to 120 MMEs or more. Beneficiaries with chronic obstructive pulmonary disease (COPD) were more likely to fill opioids (odds ratio (OR) = 1.47, 95% confidence interval (CI) = 1.46-1.47), have higher ADDs (rate ratio = 1.06, 95% CI = 1.06-1.06) when filled and were more likely to have ADD equal to 120 MMEs or more (OR = 1.23, 95% CI = 1.21-1.24). Finally, black and Hispanic beneficiaries were less likely to fill opioids, had lower overall doses and were less likely to have ADDs equal to 120 MMEs or more compared to white beneficiaries.

Conclusion: Several beneficiary subgroups have underappreciated risk of adverse events associated with ADD equal to 120 MMEs or more that may benefit from opioid optimization interventions that balance pain management and adverse event risk, especially beneficiaries with COPD who are at risk for respiratory depression.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.16911DOI Listing
February 2021

Fragmentation of care as a barrier to optimal ESKD management.

Semin Dial 2020 11 31;33(6):440-448. Epub 2020 Oct 31.

Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.

Caring for patients with end-stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system-level interventions aimed at improving care for patients with ESKD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/sdi.12929DOI Listing
November 2020

Implementation of a stepped wedge cluster randomized trial to evaluate a hospital mobility program.

Trials 2020 Oct 16;21(1):863. Epub 2020 Oct 16.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System, Durham, NC, USA.

Background: Stepped wedge cluster randomized trials (SW-CRT) are increasingly used to evaluate new clinical programs, yet there is limited guidance on practical aspects of applying this design. We report our early experiences conducting a SW-CRT to examine an inpatient mobility program (STRIDE) in the Veterans Health Administration (VHA). We provide recommendations for future research using this design to evaluate clinical programs.

Methods: Based on data from study records and reflections from the investigator team, we describe and assess the design and initial stages of a SW-CRT, from site recruitment to program launch in 8 VHA hospitals.

Results: Site recruitment consisted of thirty 1-h conference calls with representatives from 22 individual VAs who expressed interest in implementing STRIDE. Of these, 8 hospitals were enrolled and randomly assigned in two stratified blocks (4 hospitals per block) to a STRIDE launch date. Block 1 randomization occurred in July 2017 with first STRIDE launch in December 2017; block 2 randomization occurred in April 2018 with first STRIDE launch in January 2019. The primary study outcome of discharge destination will be assessed using routinely collected data in the electronic health record (EHR). Within randomized blocks, two hospitals per sequence launched STRIDE approximately every 3 months with primary outcome assessment paused during the 3-month time period of program launch. All sites received 6-8 implementation support calls, according to a pre-specified schedule, from the time of recruitment to program launch, and all 8 sites successfully launched within their assigned 3-month window. Seven of the eight sites initially started with a limited roll out (for example on one ward) or modified version of STRIDE (for example, using existing staff to conduct walks until new positions were filled).

Conclusions: Future studies should incorporate sufficient time for site recruitment and carefully consider the following to inform design of SW-CRTs to evaluate rollout of a new clinical program: (1) whether a blocked randomization fits study needs, (2) the amount of time and implementation support sites will need to start their programs, and (3) whether clinical programs are likely to include a "ramp-up" period. Successful execution of SW-CRT designs requires both adherence to rigorous design principles and also careful consideration of logistical requirements for timing of program roll out.

Trial Registration: ClinicalsTrials.gov NCT03300336 . Prospectively registered on 3 October 2017.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-020-04764-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7574435PMC
October 2020

Association of VA Payment Reform for Dialysis with Spending, Access to Care, and Outcomes for Veterans with ESKD.

Clin J Am Soc Nephrol 2020 11 22;15(11):1631-1639. Epub 2020 Sep 22.

Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Health Care System, Providence, Rhode Island.

Background And Objectives: Because of the limited capacity of its own dialysis facilities, the Department of Veterans Affairs (VA) Veterans Health Administration routinely outsources dialysis care to community providers. Prior to 2011-when the VA implemented a process of standardizing payments and establishing national contracts for community-based dialysis care-payments to community providers were largely unregulated. This study examined the association of changes in the Department of Veterans Affairs payment policy for community dialysis with temporal trends in VA spending and veterans' access to dialysis care and mortality.

Design, Setting, Participants, & Measurements: An interrupted time series design and VA, Medicare, and US Renal Data System data were used to identify veterans who received VA-financed dialysis in community-based dialysis facilities before (2006-2008), during (2009-2010), and after the enactment of VA policies to standardize dialysis payments (2011-2016). We used multivariable, differential trend/intercept shift regression models to examine trends in average reimbursement for community-based dialysis, access to quality care (veterans' distance to community dialysis, number of community dialysis providers, and dialysis facility quality indicators), and 1-year mortality over this time period.

Results: Before payment reform, the unadjusted average per-treatment reimbursement for non-VA dialysis care varied widely ($47-$1575). After payment reform, there was a 44% reduction ($44-$250) in the adjusted price per dialysis session (<0.001) and less variation in payments for dialysis ($73-$663). Over the same time period, there was an increase in the number of community dialysis facilities contracting with VA to deliver care to veterans with ESKD from 19 to 37 facilities (per VA hospital), and there were no changes in either the quality of community dialysis facilities or crude 1-year mortality rate of veterans (12% versus 11%).

Conclusions: VA policies to standardize payment and establish national dialysis contracts increased the value of VA-financed community dialysis care by reducing reimbursement without compromising access to care or survival.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.02100220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646236PMC
November 2020

Payer Mix Among Patients Receiving Dialysis-Reply.

JAMA 2020 09;324(9):901

Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2020.10774DOI Listing
September 2020

Trends in Regional Supply of Peritoneal Dialysis in an Era of Health Reform, 2006 to 2013.

Med Care Res Rev 2021 Jun 6;78(3):281-290. Epub 2020 Mar 6.

Duke University, Durham, NC, USA.

Peritoneal dialysis (PD), a home-based treatment for kidney failure, is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis. Yet <10% of patients receive PD. Access to this alternative treatment, vis-à-vis providers' supply of PD services, may be an important factor but has been sparsely studied in the current era of national payment reform for dialysis care. We describe temporal and regional variation in PD supply among Medicare-certified dialysis facilities from 2006 to 2013. The average proportion of facilities offering PD per hospital referral region increased from 40% (2006) to 43% (2013). PD supply was highest in hospital referral regions with higher percentage of facilities in urban areas ( = .004), prevalence of PD use ( < .0001), percentage of White end-stage renal disease patients ( = .02), and per capita income ( = .02). Disparities in PD access persist in rural, non-White, and low-income regions. Policy efforts to further increase regional PD supply should focus on these underserved communities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1077558720910633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483785PMC
June 2021

Implementation of a group physical therapy program for Veterans with knee osteoarthritis.

BMC Musculoskelet Disord 2020 Feb 3;21(1):67. Epub 2020 Feb 3.

Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, 508 Fulton St, Durham, NC, 27705, USA.

Background: A previous randomized clinical trial found that a Group Physical Therapy (PT) program for knee osteoarthritis yielded similar improvements in pain and function compared with traditional individual PT. Based on these findings the Group PT program was implemented in a Department of Veterans Affairs Health Care System. The objective of this study was to evaluate implementation metrics and changes in patient-level measures following implementation of the Group PT program.

Methods: This was a one-year prospective observational study. The Group PT program involved 6 weekly sessions. Implementation metrics included numbers of referrals and completed sessions. Patient-level measures were collected at the first and last PT sessions and included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC; self-report of pain, stiffness and function (range 0-96)) and a 30-s chair rise test.

Results: During the evaluation period, 152 patients were referred, 80 had an initial session scheduled, 71 completed at least one session and 49 completed at least 5 sessions. The mean number of completed appointments per patient was 4.1. Among patients completing baseline and follow-up measures, WOMAC scores (n = 33) improved from 56.8 (SD = 15.8) to 46.9 (SD = 14.0); number of chair rises (n = 38) completed in 30 s increased from 10.4 (SD = 5.1) to 11.9 (SD = 5.0).

Conclusions: Patients completing the Group PT program in this implementation phase showed clinically relevant improvements comparable to those observed in the previous clinical trial that compared group and individual PT for knee osteoarthritis. These results are important because Group PT can improve efficiency and access compared with individual PT. However, there were some limitations with respect to attendance and completion rates, and program adaptations may be needed to optimize these implementation metrics. Larger, longer-term studies are required to more fully evaluate the effectiveness of this program.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12891-020-3079-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998361PMC
February 2020

Trends in Peritoneal Dialysis Use in the United States after Medicare Payment Reform.

Clin J Am Soc Nephrol 2019 12 21;14(12):1763-1772. Epub 2019 Nov 21.

Departments of Medicine,

Background And Objectives: Peritoneal dialysis (PD) for ESKD is associated with similar mortality, higher quality of life, and lower costs compared with hemodialysis (HD), but has historically been underused. We assessed the effect of the 2011 Medicare prospective payment system (PPS) for dialysis on PD initiation, modality switches, and stable PD use.

Design, Setting, Participants, & Measurements: Using US Renal Data System and Medicare data, we identified all United States patients with ESKD initiating dialysis before (2006-2010) and after (2011-2013) PPS implementation, and observed their modality for up to 2 years after dialysis initiation. Using logistic regression models, we examined the associations between PPS and early PD experience (any PD 1-90 days after initiation), late PD use (any PD 91-730 days after initiation), and modality switches (PD-to-HD or HD-to-PD 91-730 days after initiation). We adjusted for patient, dialysis facility, and regional characteristics.

Results: Overall, 619,126 patients with incident ESKD received dialysis at Medicare-certified facilities, 2006-2013. Observed early PD experience increased from 9.4% before PPS to 12.6% after PPS. Observed late PD use increased from 12.1% to 16.1%. In adjusted analyses, PPS was associated with increased early PD experience (odds ratio [OR], 1.51; 95% confidence interval [95% CI], 1.47 to 1.55; <0.001) and late PD use (OR, 1.47; 95% CI, 1.45 to 1.50; <0.001). In subgroup analyses, late PD use increased in part due to an increase in HD-to-PD switches among those without early PD experience (OR, 1.59; 95% CI, 1.52 to 1.66; <0.001) and a decrease in PD-to-HD switches among those with early PD experience (OR, 0.92; 95% CI, 0.87 to 0.98; =0.004).

Conclusions: More patients started, stayed on, and switched to PD after dialysis payment reform. This occurred without a substantial increase in transfers to HD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.05910519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6895485PMC
December 2019

An electronic family health history tool to identify and manage patients at increased risk for colorectal cancer: protocol for a randomized controlled trial.

Trials 2019 Oct 7;20(1):576. Epub 2019 Oct 7.

William S Middleton Memorial Veterans Hospital, Madison, WI, USA.

Background: Colorectal cancer is the fourth most commonly diagnosed cancer in the United States. Approximately 3-10% of the population has an increased risk for colorectal cancer due to family history and warrants more frequent or intensive screening. Yet, < 50% of that high-risk population receives guideline-concordant care. Systematic collection of family health history and decision support may improve guideline-concordant screening for patients at increased risk of colorectal cancer. We seek to test the effectiveness of a web-based, systematic family health history collection tool and decision support platform (MeTree) to improve risk assessment and appropriate management of colorectal cancer risk among patients in the Department of Veterans Affairs primary care practices.

Methods: In this ongoing randomized controlled trial, primary care providers at the Durham Veterans Affairs Health Care System and the Madison VA Medical Center are randomized to immediate intervention or wait-list control. Veterans are eligible if assigned to enrolled providers, have an upcoming primary care appointment, and have no conditions that would place them at increased risk for colorectal cancer (such as personal history, adenomatous polyps, or inflammatory bowel disease). Those with a recent lower endoscopy (e.g. colonoscopy, sigmoidoscopy) are excluded. Immediate intervention patients put their family health history information into a web-based platform, MeTree, which provides both patient- and provider-facing decision support reports. Wait-list control patients access MeTree 12 months post-consent. The primary outcome is the risk-concordant colorectal cancer screening referral rate obtained via chart review. Secondary outcomes include patient completion of risk management recommendations (e.g. colonoscopy) and referral for genetic consultation. We will also conduct an economic analysis and an assessment of providers' experience with MeTree clinical decision support recommendations to inform future implementation efforts if the intervention is found to be effective.

Discussion: This trial will assess the feasibility and effectiveness of patient-collected family health history linked to decision support to promote risk-appropriate screening in a large healthcare system such as the Department of Veterans Affairs.

Trial Registration: ClinicalTrials.gov, NCT02247336 . Registered on 25 September 2014.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-019-3659-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781340PMC
October 2019

Lab-based and diagnosis-based chronic kidney disease recognition and staging concordance.

BMC Nephrol 2019 09 14;20(1):357. Epub 2019 Sep 14.

Division of General Internal Medicine, Department of Medicine, Duke University School of Medicine, Durham, USA.

Background: Chronic kidney disease (CKD) is often under-recognized and poorly documented via diagnoses, but the extent of under-recognition is not well understood among Medicare beneficiaries. The current study used claims-based diagnosis and lab data to examine patient factors associated with clinically recognized CKD and CKD stage concordance between claims- and lab-based sources in a cohort of Medicare beneficiaries.

Methods: In a cohort of fee-for-service (FFS) beneficiaries with CKD based on 2011 labs, we examined the proportion with clinically recognized CKD via diagnoses and factors associated with clinical recognition in logistic regression. In the subset of beneficiaries with CKD stage identified from both labs and diagnoses, we examined concordance in CKD stage from both sources, and factors independently associated with CKD stage concordance in logistic regression.

Results: Among the subset of 206,036 beneficiaries with lab-based CKD, only 11.8% (n = 24,286) had clinically recognized CKD via diagnoses. Clinical recognition was more likely for beneficiaries who had higher CKD stages, were non-elderly, were Hispanic or non-Hispanic Black, lived in core metropolitan areas, had multiple chronic conditions or outpatient visits in 2010, or saw a nephrologist. In the subset of 18,749 beneficiaries with CKD stage identified from both labs and diagnoses, 70.0% had concordant CKD stage, which was more likely if beneficiaries were older adults, male, lived in micropolitan areas instead of non-core areas, or saw a nephrologist.

Conclusions: There is significant under-diagnosis of CKD in Medicare FFS beneficiaries, which can be addressed with the availability of lab results.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12882-019-1551-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6744668PMC
September 2019

Improving Access to Kidney Transplantation: Business as Usual or New Ways of Doing Business?

JAMA 2019 09;322(10):931-933

Department of Medicine, Priscilla Chan and Mark Zuckerberg San Francisco General Hospital, University of California, San Francisco.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jama.2019.12784DOI Listing
September 2019

Adaptation and Implementation of a Family Caregiver Skills Training Program: From Single Site RCT to Multisite Pragmatic Intervention.

J Nurs Scholarsh 2020 01 9;52(1):23-33. Epub 2019 Sep 9.

Core Faculty, Margolis Center for Health Policy, Duke University, Durham, NC, USA.

Purpose: We describe an approach to rapidly adapt and implement an education and skills improvement intervention to address the needs of family caregivers of functionally impaired veterans-Helping Invested Families Improve Veterans' Experience Study (HI-FIVES).

Design: Prior to implementation in eight sites, a multidisciplinary study team made systematic adaptations to the curriculum content and delivery process using input from the original randomized controlled trial (RCT); a stakeholder advisory board comprised of national experts in caregiver education, nursing, and implementation; and a veteran/caregiver engagement panel. To address site-specific implementation barriers in diverse settings, we applied the Replicating Effective Programs implementation framework.

Findings: Adaptations to HI-FIVES content and delivery included identifying core/noncore curriculum components, reducing instruction time, and simplifying caregiver recruitment for clinical settings. To enhance curriculum flexibility and potential uptake, site personnel were able to choose which staff would deliver the intervention and whether to offer class sessions in person or remotely. Curriculum materials were standardized and packaged to reduce the time required for implementation and to promote fidelity to the intervention.

Conclusions: The emphasis on flexible intervention delivery and standardized materials has been identified as strengths of the adaptation process. Two key challenges have been identifying feasible impact measures and reaching eligible caregivers for intervention recruitment.

Clinical Relevance: This systematic implementation process can be used to rapidly adapt an intervention to diverse clinical sites and contexts. Nursing professionals play a significant role in educating and supporting caregivers and care recipients and can take a leading role to implement interventions that address skills and unmet needs for caregivers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jnu.12511DOI Listing
January 2020

Implementing a Mandated Program Across a Regional Health Care System: A Rapid Qualitative Assessment to Evaluate Early Implementation Strategies.

Qual Manag Health Care 2019 Jul/Sep;28(3):147-154

Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina (Drs Sperber, Wang, Jackson, Van Houtven, Allen, and Hastings and Mss Bruening, Choate, and Mahanna); Department of Population Health Sciences (Drs Sperber, Wang, Jackson, Van Houtven, and Hastings), Division of General Internal Medicine (Dr Wang), and Division of Geriatrics, Department of Medicine and Center for the Study of Aging (Dr Hastings), Duke University School of Medicine, Durham, North Carolina; Department of Health Policy and Management, Gillings School of Global Public Health (Dr Powell), and Department of Medicine & Thurston Arthritis Research Center (Dr Allen), University of North Carolina, Chapel Hill, North Carolina; Center for Health Information and Communication, Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana (Dr Damush); and Department of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis (Dr Damush).

Background: Rapid qualitative assessment was used to describe early strategies to implement an evidence-based walking program for hospitalized older adults, assiSTed eaRly mobIlity for hospitalizeD older vEterans (STRIDE), mandated by a regional Department of Veterans Affairs health care system office (Veterans Integrated Service Network [VISN]).

Methods: Data were collected from 6 hospital sites via semistructured interviews with key informants, observations of telephone-based technical assistance, and review of VISN-requested program documents (eg, initial implementation plans). An overarching framework of actionable feedback for VISN leadership and specification of locally initiated implementation strategies, using the Expert Recommendations for Implementing Change (ERIC) compilation, was used. Actionable feedback was shared with VISN leadership 1 month after the initiative.

Results: ERIC implementation strategies identified were as follows: (1) promoting adaptability-4 sites had physical therapists/kinesiotherapists instead of assistants walk patients; (2) promoting network weaving-strengthening nursing and PT/KT partnership with regular communication opportunities or a point person was important for implementation; (3) distributing educational materials-2 sites distributed information about STRIDE via e-mail and in person; and (4) organizing clinician implementation team meetings-3 sites used interdisciplinary team meetings to communicate with the clinical staff about STRIDE.

Conclusion: This qualitative study sheds light on early experiences with implementing STRIDE; the results have been instructive for ongoing implementation and future dissemination of STRIDE, and the approach can be applied across contexts to inform implementation of other programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/QMH.0000000000000221DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7558850PMC
April 2020

Care continuity impacts medicare expenditures of older adults: Fact or fiction?

Healthc (Amst) 2020 Mar 30;8(1):100364. Epub 2019 May 30.

Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, USA; Department of Population Health Sciences, Duke University School of Medicine, USA; Division of General Internal Medicine, Duke University School of Medicine, USA; Duke Clinical Research Institute, Duke University Medical Center, USA.

Background: Older adults with cardiometabolic conditions are typically seen by multiple providers. Management by multiple providers may compromise care continuity and increase health expenditures for older adults, which may partly explain the inverse association between continuity and Medicare expenditures found in prior studies. This study sought to examine whether all-cause admission, outpatient expenditures or total expenditures were associated with the number of prescribers of cardiometabolic medications.

Methods: Medicare fee-for-service beneficiaries with diabetes (n = 100,191), hypertension (n = 299,949) or dyslipidemia (n = 243,598) living in 10 states were identified from claims data. The probability of an all-cause hospital admission in 2011 was estimated via logistic regression and Medicare (outpatient, total) expenditures in 2011 were estimated using generalized linear models, both as a function of the number of prescribers in 2010. Regressions were adjusted for demographic characteristics, Medicaid status, number of prescriptions, and 17 chronic conditions.

Results: In all three cohorts, older adults with more prescribers in 2010 had modestly higher adjusted odds of all-cause inpatient admission than older adults with a single prescriber. Compared to a single prescriber, outpatient and total expenditures in 2011 were 3-10% higher for older adults with diabetes and multiple prescribers, 2-6% higher for older adults with hypertension and multiple prescribers, and 2-5% higher for older adults with dyslipidemia and multiple prescribers.

Conclusions And Implications: These results provide some evidence that older adults with multiple prescribers also have modestly higher Medicare utilization than those with a single prescriber; thus care continuity may impact patient utilization.

Level Of Evidence: Level III (retrospective cohort analysis).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hjdsi.2019.05.004DOI Listing
March 2020

Patient Outcomes and Dialysis Consolidation-Two Big to Fail?

JAMA Netw Open 2019 05 3;2(5):e193962. Epub 2019 May 3.

Center of Innovation to Accelerate Discovery & Practice Transformation, Durham Veterans Affairs Medical Center, Durham, North Carolina.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2019.3962DOI Listing
May 2019

Authors' Reply.

J Am Soc Nephrol 2019 07 16;30(7):1338-1339. Epub 2019 May 16.

Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1681/ASN.2019040402DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6622422PMC
July 2019

Early Mobility in the Hospital: Lessons Learned from the STRIDE Program.

Geriatrics (Basel) 2018 Dec 26;3(4). Epub 2018 Sep 26.

Center of Innovation for Health Services Research in Primary Care, Durham VA Health Care System, Durham, NC 27705, USA; (A.L.C.); (E.P.M.); (K.D.A.); (C.H.V.H.); (V.W.).

Immobility during hospitalization is widely recognized as a contributor to deconditioning, functional loss, and increased need for institutional post-acute care. Several studies have demonstrated that inpatient walking programs can mitigate some of these negative outcomes, yet hospital mobility programs are not widely available in U.S. hospitals. STRIDE (assiSTed eaRly mobIlity for hospitalizeD older vEterans) is a supervised walking program for hospitalized older adults that fills this important gap in clinical care. This paper describes how STRIDE works and how it is being disseminated to other hospitals using the Replicating Effective Programs (REP) framework. Guided by REP, we define core components of the program and areas where the program can be tailored to better fit the needs and local conditions of its new context (hospital). We describe key adaptations made by four hospitals who have implemented the STRIDE program and discuss lessons learned for successful implementation of hospital mobility programs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3390/geriatrics3040061DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6371091PMC
December 2018

Survival among Veterans Obtaining Dialysis in VA and Non-VA Settings.

J Am Soc Nephrol 2019 01 7;30(1):159-168. Epub 2018 Dec 7.

Health Services Research and Development, Durham Veterans Affairs Health Care System, Durham, North Carolina.

Background: Outcomes of veterans with ESRD may differ depending on where they receive dialysis and who finances this care, but little is known about variation in outcomes across different dialysis settings and financial arrangements.

Methods: We examined survival among 27,241 Veterans Affairs (VA)-enrolled veterans who initiated chronic dialysis in 2008-2011 at () VA-based units, () community-based clinics through the Veterans Affairs Purchased Care program (VA-PC), () community-based clinics under Medicare, or () more than one of these settings ("dual" care). Using a Cox proportional hazards model, we compared all-cause mortality across dialysis settings during the 2-year period after dialysis initiation, adjusting for demographic and clinical characteristics.

Results: Overall, 4% of patients received dialysis in VA, 11% under VA-PC, 67% under Medicare, and 18% in dual settings (nearly half receiving dual VA and VA-PC dialysis). Crude 2-year mortality was 25% for veterans receiving dialysis in the VA, 30% under VA-PC, 42% under Medicare, and 23% in dual settings. After adjustment, dialysis patients in VA or in dual settings had significantly lower 2-year mortality than those under Medicare; mortality did not differ in VA-PC and Medicare dialysis settings.

Conclusions: Mortality rates were highest for veterans receiving dialysis in Medicare or VA-PC settings and lowest for veterans receiving dialysis in the VA or dual settings. These findings inform institutional decisions about provision of dialysis for veterans. Further research identifying processes associated with improved survival for patients receiving VA-based dialysis may be useful in establishing best practices for outsourced veteran care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1681/ASN.2018050521DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6317601PMC
January 2019

Medicare's New Prospective Payment System on Facility Provision of Peritoneal Dialysis.

Clin J Am Soc Nephrol 2018 12 19;13(12):1833-1841. Epub 2018 Nov 19.

Departments of Population Health Sciences and.

Background And Objectives: Peritoneal dialysis is a self-administered, home-based treatment for ESKD associated with equivalent mortality, higher quality of life, and lower costs compared with hemodialysis. In 2011, Medicare implemented a comprehensive prospective payment system that makes a single payment for all dialysis, medication, and ancillary services. We examined whether the prospective payment system increased dialysis facility provision of peritoneal dialysis services and whether changes in peritoneal dialysis provision were more common among dialysis facilities that are chain affiliated, located in nonurban areas, and in regions with high dialysis market competition.

Design, Setting, Participants, & Measurements: We conducted a longitudinal retrospective cohort study of =6433 United States nonfederal dialysis facilities before (2006-2010) and after (2011-2013) the prospective payment system using data from the US Renal Data System, Medicare, and Area Health Resource Files. The outcomes of interest were a dichotomous indicator of peritoneal dialysis service availability and a discrete count variable of dialysis facility peritoneal dialysis program size defined as the annual number of patients on peritoneal dialysis in a facility. We used general estimating equation models to examine changes in peritoneal dialysis service offerings and peritoneal dialysis program size by a pre- versus post-prospective payment system effect and whether changes differed by chain affiliation, urban location, facility size, or market competition, adjusting for 1-year lagged facility-, patient with ESKD-, and region-level demographic characteristics.

Results: We found a modest increase in observed facility provision of peritoneal dialysis and peritoneal dialysis program size after the prospective payment system (36% and 5.7 patients in 2006 to 42% and 6.9 patients in 2013, respectively). There was a positive association of the prospective payment system with peritoneal dialysis provision (odds ratio, 1.20; 95% confidence interval, 1.13 to 1.18) and PD program size (incidence rate ratio, 1.27; 95% confidence interval, 1.22 to 1.33). Post-prospective payment system change in peritoneal dialysis provision was greater among nonurban (<0.001), chain-affiliated (=0.002), and larger-sized facilities (<0.001), and there were higher rates of peritoneal dialysis program size growth in nonurban facilities (<0.001).

Conclusions: Medicare's 2011 prospective payment system was associated with more facilities' availability of peritoneal dialysis and modest growth in facility peritoneal dialysis program size.

Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2018_11_19_CJASNPodcast_18_12_.mp3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2215/CJN.05680518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6302340PMC
December 2018

Comparative Assessment of Utilization and Hospital Outcomes of Veterans Receiving VA and Non-VA Outpatient Dialysis.

Health Serv Res 2018 12 9;53 Suppl 3:5309-5330. Epub 2018 Aug 9.

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

Objective: Growing demand for VA dialysis exceeds its supply and travel distances prohibit many Veterans from receiving dialysis in a VA facility, leading to increased use of dialysis from non-VA providers. This study compared utilization and hospitalization outcomes among Veterans receiving chronic dialysis in VA and non-VA settings in 2008-2013.

Data Sources: VA, Medicare, and national disease registry data.

Study Design: National cohort of 27,301 Veterans initiating dialysis, observed for a period of 2 years after treatment initiation. We used multinomial logistic regression to examine associations between patient characteristics and dialysis use in VA, non-VA community settings via VA Purchased Care (VA-PC), community settings via Medicare, or Dual settings. Zero-inflated negative binomial regression was used to compare risk of hospitalization and days spent in the hospital across dialysis settings.

Principal Findings: Sixty-seven percent of Veterans obtained community-based dialysis exclusively via Medicare, 11 percent in the community via VA-PC, 4 percent in VA, and 18 percent in Dual settings. Financial and geographic access factors were important predictors of dialysis setting, but days spent in the hospital and risk of hospitalization did not differ meaningfully across settings.

Conclusions: Most Veterans obtained dialysis in the community. Dialysis setting appeared to have little impact on risk of hospitalization among Veterans.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/1475-6773.13022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6235811PMC
December 2018

Supporting teams to optimize function and independence in Veterans: a multi-study program and mixed methods protocol.

Implement Sci 2018 04 20;13(1):58. Epub 2018 Apr 20.

Health Services Research and Development Center of Innovation, Durham Veterans Affairs Health Care System, 508 Fulton St., Durham, NC, 27705, USA.

Background: Successful implementation of new clinical programs depends on effectively establishing, reorganizing, or enhancing team structures and processes to coordinate the work of individuals who are interdependent in their tasks, manage relationships, and share responsibility for outcomes. However, a one-size-fits-all approach is rarely effective. In partnership with VA national clinical leaders and local clinical champions, the Optimizing Function and Independence VA Quality Enhancement Research Initiative program (Function QUERI) will evaluate efforts to implement team-based clinical programs for Veterans at risk for functional decline and disability.

Methods: Function QUERI will implement and evaluate three innovative, evidence-based clinical programs in VA medical centers: (1) a group physical therapy program for knee osteoarthritis (Group PT); (2) assisted early mobility for hospitalized older veterans (STRIDE), a supervised walking program for hospitalized older veterans; and (3) implementation of helping invested family members improve veteran experiences study (iHI-FIVES), a skills training program for caregivers of disabled Veterans. A common reason for clinical care gaps in these populations is poor communication and coordination among the many interdisciplinary providers involved in their care. To facilitate the implementation of the clinical programs, Function QUERI will evaluate the impact of complexity science-based implementation intervention to promote team readiness (CONNECT), an implementation intervention designed as a bundle of interaction-oriented activities to promote team function and readiness for change, on the implementation of clinical programs across multiple sites. The evaluation will use a mixed methods design. Group PT is a local, single-site quality improvement project where a modified CONNECT intervention will be tested to inform the remaining program implementation projects. For STRIDE and iHI-FIVES projects, we will randomize participating sites to implement the clinical program, with the CONNECT intervention or not, and will use a stepped-wedge cluster randomized trial design.

Discussion: Function QUERI will translate its findings across its projects to identify the contextual factors and components from CONNECT that improve team processes and function to optimize effective implementation for future rollout of VA clinical programs. Synthesizing findings within and across projects, we will specify dimensions of team characteristics and function that enhance capacity for clinical innovation and uptake of evidence-based programs.

Trial Registration: NCT03300336 Registered September 28, 2017, NCT03474380 Registered March 15, 2018.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13012-018-0748-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5910600PMC
April 2018

Prescriber continuity and medication availability in older adults with cardiometabolic conditions.

SAGE Open Med 2018 6;6:2050312118757388. Epub 2018 Feb 6.

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

Background: Many older adults have multiple conditions and see multiple providers, which may impact their use of essential medications.

Objective: We examined whether the number of prescribers of these medications was associated with the availability of medications, a surrogate for adherence, to manage diabetes, hypertension or dyslipidemia.

Methods: A retrospective cohort of 383,145 older adults with diabetes, hypertension or dyslipidemia in the US Medicare program living in 10 states. The association between the number of prescribers of cardiometabolic medications in 2010 and medication availability (proportion of days with medication on hand) in 2011 was estimated via logistic regression, controlling for patient demographic characteristics and chronic conditions.

Results: Medicare beneficiaries with diabetes, hypertension and/or dyslipidemia had an average of five chronic conditions overall, obtained 10-12 medications for all conditions and most often had one prescriber of cardiometabolic medications. In adjusted analyses, the number of prescribers was not significantly associated with availability of oral diabetes agents but having more prescribers is associated with increased medication availability in older Medicare beneficiaries with dyslipidemia or hypertension.

Conclusion: The incremental addition of new prescribers may be clinically reasonable for complex patients but creates the potential for coordination problems and informational discontinuity over time. Health systems may want to identify complex patients with multiple prescribers to minimize care fragmentation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2050312118757388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5808964PMC
February 2018

Working smarter not harder: Coupling implementation to de-implementation.

Healthc (Amst) 2018 Jun 24;6(2):104-107. Epub 2017 Dec 24.

Department of Health Services, School of Public Health, University of Washington, USA; Department of Global Health, School of Public Health, University of Washington, USA. Electronic address:

In this paper, we discuss de-implementation as an implicit part of implementation and organizational change, and consider its underlying processes of unlearning to discontinue or deviate from ineffective practice and learning to applying newer, more effective practices. We describe a typology of de-implementation that represents four types of change: partial reduction, complete reversal, substitution with related replacement and substitution with unrelated replacement of existing practice. We also explicate how learning and unlearning needed for effective change vary in these four types of de-implementation. Last, we propose coupling de-implementation and implementation efforts, which serve conceptual and logistical goals of organizational change.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hjdsi.2017.12.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5999540PMC
June 2018

Minding the gap and overlap: a literature review of fragmentation of primary care for chronic dialysis patients.

BMC Nephrol 2017 Aug 29;18(1):274. Epub 2017 Aug 29.

Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Background: Care coordination is a challenge for patients with kidney disease, who often see multiple providers to manage their associated complex chronic conditions. Much of the focus has been on primary care physician (PCP) and nephrologist collaboration in the early stages of chronic kidney disease, but less is known about the co-management of the patients in the end-stage of renal disease. We conducted a systematic review and synthesis of empirical studies on primary care services for dialysis patients.

Methods: Systematic literature search of MEDLINE/PubMED, CINAHL, and EmBase databases for studies, published until August 2015. Inclusion criteria included publications in English, empirical studies involving human subjects (e.g., patients, physicians), conducted in US and Canadian study settings that evaluated primary care services in the dialysis patient population.

Results: Fourteen articles examined three major themes of primary care services for dialysis patients: perceived roles of providers, estimated time in providing primary care, and the extent of dialysis patients' use of primary care services. There was general agreement among providers that PCPs should be involved but time, appropriate roles, and miscommunication are potential barriers to good primary care for dialysis patients. Although many dialysis patients report having a PCP, the majority rely on primary care from their nephrologists. Studies using administrative data found lower rates of preventive care services than found in studies relying on provider or patient self-report.

Discussion: The extant literature revealed gaps and opportunities to optimize primary care services for dialysis patients, foreshadowing the challenges and promise of Accountable Care / End-Stage Seamless Care Organizations and care coordination programs currently underway in the United States to improve clinical and logistical complexities of care for this commonly overlooked population. Studies linking the relationship between providers and patients' receipt of primary care to outcomes will serve as important comparisons to the nascent care models for ESRD patients, whose value is yet to be determined.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12882-017-0689-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5576103PMC
August 2017
-->