Change Health Care Providers Research Articles

“TEG” talks: technology worth spreading?

“TEG” talks: technology worth spreading?

NeuroMeasures-Implementation of a Web-Based, Real-Time Quality Metric Tool to Improve Provider Practices in an Epilepsy Clinic.

The retrospective nature of most available epilepsy quality improvement (QI) tools focuses on changing health care provider (HCP) clinical habits and documentation practices rather than a focus on real-time patient interventions. Furthermore, patient-reported outcome data are often not available to determine the efficacy of these tools. Our primary objective was to demonstrate the improvement of HCPs' documentation and review of epilepsy quality measures (EQMs) during the patient visit with the implementation of a novel web application, NeuroMeasures. Our secondary objective was to improve the percentage of point-of-care counseling and interventions based on quality measures during the patient encounter based on the results of the NeuroMeasures tool. Our QI study focused on comparing a preintervention and postintervention cohort of patients with epilepsy (PWE) before the implementation of NeuroMeasures, a web-based application that takes a self-guided patient survey through self-scoring algorithms focused on the American Academy of Neurology (AAN)'s 2017 EQMs. This e-tool then provides the HCP a tool to directly review the EQMs highlighted and perform any necessary counseling or interventions at the point-of-care visit. After intervention, EQMs were gained from the review of the NeuroMeasures HCP quality measures tool and a chart review for physician documentation. Patients with language barriers and severe cognitive disabilities were excluded from the study. The preintervention cohort consisted of 150 unique PWE, and the postintervention cohort included 379 unique adult PWE and 515 total encounters. Overall percentages of review/adherence of EQMs were significantly improved between the preintervention and postintervention group for counseling for women of childbearing potential (91.7%), intractable epilepsy referral to a comprehensive epilepsy center (74%), quality of life assessment (80%), improvement of quality of life measurements (41.7%), and depression and anxiety screening (85.6%), demonstrating a significant increase when compared with the preintervention group (p < 0.00001). A web-based point-of-care EQM application demonstrated significant improvement of the HCP's ability to perform and review EQMs at the point-of-care patient visit. Furthermore, the application was successful in creating opportunities for direct intervention based on the EQMs and chances for better patient education and provider-patient communication. Further considerations would include automated survey requests and expansion into other AAN QMs.

How Would Medicare for All Affect Health System Capacity? Evidence from Medicare for Some

Proposals to create a national health care plan such as “Medicare for All” rely heavily on reducing the prices that insurers pay for health care. These changes affect physicians’ short-run incentives for care provision and may also change health care providers’ incentives to invest in capacity, thereby influencing the availability of care in the long term. We provide evidence on these responses using a major Medicare payment change combined with survey data on physicians’ time use. We find evidence that physicians increase their time spent on capacity building when remuneration increases, and that they are subsequently more willing to accept new patients—especially those who may be the residual claimants on marginal capacity. These forces imply that short-run supply curves likely differ from long-run supply curves. Policymakers need to account for how major changes to payment incentives would influence the investments that determine health system capacity.

How Would Medicare for All Affect Health System Capacity? Evidence from Medicare for Some

Proposals to create a national health care plan such as for All rely heavily on reducing the prices that insurers pay for health care. These changes affect physicians' short-run incentives for care provision and may also change health care providers' incentives to invest in capacity, thereby influencing the availability of care in the long term. We provide evidence on these responses using a major Medicare payment change combined with survey data on physicians' time use. We find evidence that physicians increase their time spent on capacity building when remuneration increases, and that they are subsequently more willing to accept new patients---especially those who may be the residual claimants on marginal capacity. These forces imply that short-run supply curves likely differ from long-run supply curves. Policymakers need to account for how major changes to payment incentives would influence the investments that determine health system capacity.

Lifetime Prevalence and Correlates of Patient-Perceived Medical Errors Experienced in the U.S. Ambulatory Setting: A Population-Based Study.

Background: The rate of safety harm self-perceived medical errors and harms reported in the U.S. ambulatory system is not well characterized.Objectives: To determine the prevalence of U.S. adult ambulatory care patient self-perceived safety harms and to gauge the degree of association between harms with various patient characteristics and outcomes.Methods: A large U.S. cross-sectional online survey of 9206 ambulatory care adults was assessed for their perception of medical errors and harms during care (misdiagnosis, mistakes in care, and wrong or delayed treatment) and also included patient demographics, health status, comorbidities, insurance status, income, barriers to care (affordability, transportation, and family and social support), number of visits to primary health care services in the past 12 months, and use of urgent or emergency care in the last 12 months.Results: The overall rate of self-perceived medical errors and harms among adult patients in the ambulatory care setting was 36%. Female patients, independent of age, and those with multiple comorbidities or barriers to care, reported the highest number of medical errors. Utilization of multiple providers was associated with a greater number of reported medical errors, often resulting in changing health care providers. Patients who reported having trouble affording health care or navigating the system to receive care also reported higher levels of harm. They were cared for by multiple providers, often switch providers, and their care is associated with greater utilization of health care resources. Patients reporting the highest rates of harm had greater use of hospital and emergency room care.Conclusions: This large U.S. adult ambulatory care study provides evidence that patient self-perceived medical errors and harms reported by patients are common. Patient self-perceived medical errors and harms occur most commonly in women, with poor health, limitation of activities, and who have three or more comorbidities.

User-centred participatory design of visual cues for isolation precautions

BackgroundIsolation precautions are intended to prevent transmission of infectious agents, yet healthcare provider (HCP) adherence remains suboptimal. This may be due to ambiguity regarding the required precautions or to cognitive overload of HCPs. In response to the challenge of changing HCP behaviour, increasing attention should be paid to the role of engineering controls and facility design that incorporate human factors elements. In the current study, we aimed to develop an isolation precaution signage system that provides visual cues, serves as a cognitive aid at the point of care, and removes ambiguity regarding which precautions are necessary (e.g. masks, gowns, gloves, single rooms) when caring for isolated patients.MethodsWe employed a user-centred, participatory design approach in which HCPs were actively involved in generating an isolation precaution signage system based on human factors design principles. HCPs were purposefully sampled for each design phase to include a representative sample of potential system users. We conducted front-end analysis through interviews and observations to identify challenges related to the existing signage and to establish design requirements for new signage. This was followed by the creation of user personas, design thinking workshops, and prototyping, which then underwent iterative cycles of evaluation. Graphical symbols were developed and tested for comprehensibility.ResultsFront-end analysis revealed several barriers to use of the current signage system such as unclear target audience, low signal-to-noise ratio, and ambiguity regarding the applicable precautions. A comprehensive list of design requirements was generated. The project ultimately resulted in a collection of validated, comprehensible symbols and signs for contact, droplet, and airborne isolation, as well as the identification of several systems-level solutions for work re-organisation to improve compliance with isolation precautions.ConclusionsThe introduction of visual cues in the form of signage offers a promising opportunity to make guidelines available directly at the frontline. Anecdotal evidence based on observations and interviews with HCP have shown that the current solution is superior to previous isolation signage. User-centred participatory design was a useful approach that holds potential for further improving design in healthcare settings.

Nurse Practitioner Job Satisfaction and the Healthy Work Environment.

Nurse Practitioner Job Satisfaction and the Healthy Work Environment.

Review of implementation strategies to change healthcare provider behaviour in the emergency department.

Advances in emergency medicine research can be slow to make their way into clinical care, and implementing a new evidence-based intervention can be challenging in the emergency department. The Canadian Association of Emergency Physicians (CAEP) Knowledge Translation Symposium working group set out to produce recommendations for best practice in the implementation of a new science in Canadian emergency departments. A systematic review of implementation strategies to change health care provider behaviour in the emergency department was conducted simultaneously with a national survey of emergency physician experience. We summarized our findings into a list of draft recommendations that were presented at the national CAEP Conference 2017 and further refined based on feedback through social media strategies. We produced 10 recommendations for implementing new evidence-based interventions in the emergency department, which cover identifying a practice gap, evaluating the evidence, planning the intervention strategy, monitoring, providing feedback during implementation, and desired qualities of future implementation research. We present recommendations to guide future emergency department implementation initiatives. There is a need for robust and well-designed implementation research to guide future emergency department implementation initiatives.

Modifiable Risk Factors for Stroke and Strategies for Stroke Prevention.

AbstractThe pathophysiology of stroke is well characterized, and 9 out of 10 strokes are due to modifiable factors. However, preventive strategies thus far have been relatively ineffective in curbing the global stroke burden, which is projected to increase given the aging of the world's population and epidemiological transition in many low- to middle-income countries. In this review we will summarize our current understanding of behavioral, environmental, and metabolic stroke risk factors not covered elsewhere in this issue. Specifically, we will review the evidence for environmental and household air pollution, smoking, and alcohol use. We will subsequently provide a conceptual framework for stroke prevention strategies, categorizing them as those aimed at changing health care systems and/or provider behavior and those targeting behaviors of patients and/or their caregivers, families, and support networks. The field of stroke prevention is relatively nascent, and little is known about how to optimize health care systems so that providers prescribe evidence-based care for stroke prevention, patients have access to care to receive such services, adherence and control of risk factors are optimized, and patients are empowered to manage their own risk factors and make lifestyle changes, including eating healthy diets (high in fruits, vegetables, and whole grains and low in sodium and sugar-sweetened beverages), engaging in regular physical activity, not smoking, and limiting alcohol consumption. In the next several years, we will likely develop a better understanding of which strategies are effective for modifying vascular risk factors, and how to design and implement successful interventions. Key questions to be answered include optimal theoretical frameworks, delivery models, team composition, timing, dose, intensity, and frequency, taking into account cultural, sociodemographic, and regional differences in patient populations.

Changing health care provider performance through measurement

Can the quality of care be improved by repeated measurement? We show that measuring protocol adherence repeatedly over ten weeks leads to significant improvements in quality immediately and up to 18 months later without any additional training, equipment, supplies or material incentives. 96 clinicians took part in a study which included information, encouragement, scrutiny and repeated contact with the research team measuring quality. We examine protocol adherence over the course of the study and for 45 of the original clinicians 18 months after the conclusion of the project. Health workers change their behavior significantly over the course of the study, and even eighteen months later demonstrate a five percentage point improvement in quality. The dynamics of clinicians’ reactions to this intervention suggest that quality can be improved by the repeated measurement by external peers in a way that provides reminders of expectations.

Learning (or Not) in Health-Seeking Behavior: Evidence from Rural Tanzania

The aim of this article is to understand the functioning of individuals’ health-seeking behavior. It studies, theoretically and empirically, whether individuals change health care providers over time, depending on the health outcome (i.e., healed or sick) after consultation with the previous caregiver. Results show that the previous health outcome plays a crucial role in shifting individual preferences to a particular type of medical care. I find that patients who healed after seeking health care are more likely to seek care again in the future. Furthermore, conditional on seeking care, individuals are more likely to return to formal (informal) health providers with whom they have experienced a previous history of cures and switch away from formal (informal) caregivers with whom they had a negative outcome. I interpret these results as learning about clinicians’ quality over time. The effects are tested using 4-year panel data from a household survey in Tanzania.

Chronic Care Model Decision Support and Clinical Information Systems Interventions for People Living with HIV: A Systematic Review

BACKGROUNDThe Chronic Care Model is an effective framework for improving chronic disease management. There is scarce literature describing this model for people living with HIV. Decision Support (DS) and Clinical Information Systems (CIS) are two components of this model that aim to improve care by changing health care provider behavior.OBJECTIVEOur aim was to assess the effectiveness of DS and CIS interventions for individuals with HIV, through a systematic literature review.DESIGNWe performed systematic electronic searches from 1996 to February 2011 of the medical (E.g. Medline, EMBASE, CINAHL) and grey literature. Effectiveness was measured by the frequency of statistically significant outcome improvement. Data and key equity indicator extraction and synthesis was completed.PARTICIPANTS AND INTERVENTIONSWe included comparative studies of people living with HIV that examined the impact of DS or CIS interventions on outcomes.MAIN MEASURESThe following measures were assessed: outcome (immunological/virological, medical, psychosocial, economic measures) and health care process/performance measures.KEY RESULTSRecords were screened for relevance (n = 10,169), full-text copies of relevant studies were obtained (n = 123), and 16 studies were included in the review. Overall, 5/9 (55.6%) and 17/41 (41.5%) process measures and 5/12 (41.7%) and 3/9 (33.3%) outcome measures for DS and CIS interventions, respectively, were statistically significantly improved. DS–explicit mention of implementation of guidelines and CIS-reminders showed the most frequent improvement in outcomes. DS-only interventions were more effective than CIS-only interventions in improving both process and outcome measures. Clinical, statistical and methodological heterogeneity among studies precluded meta-analysis. Primary studies were methodologically weak and often included multifaceted interventions that made assessment of effectiveness challenging.CONCLUSIONSOverall, DS and CIS interventions may modestly improve care for people living with HIV, having a greater impact on process measures compared to outcome measures. These interventions should be considered as part of strategies to improve HIV care through changing provider performance.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-012-2145-y) contains supplementary material, which is available to authorized users.

Changing Health Care Providers’ Behavior During Pediatric Inductions With an Empirically Based Intervention

Changing Health Care Providers’ Behavior During Pediatric Inductions With an Empirically Based Intervention

Acute Care Pediatric Nurse Practitioner: A Vital Role in Pediatric Cardiothoracic Surgery

The changing health care environment and provider shortage have required acute care pediatric nurse practitioners (AC PNPs) to play a vital role in hospital-based, subspecialty surgical services. The AC PNP is part of a multidisciplinary team providing care for children with congenital heart disease after heart surgery. The AC PNP provides high-quality, cost-effective care to acute and critically ill children, optimizing hospital throughput while ensuring patient safety. This article focuses on the history and emerging role of the AC PNP in the context of the Magnet component of transformational leadership, the physician/nurse practitioner collaborative practice, and the development of the AC PNP role in cardiothoracic surgery at the Children's Hospital Los Angeles.

Features predicting the success of computerized decision support for prescribing: a systematic review of randomized controlled trials

BackgroundComputerized decision support systems (CDSS) are believed to have the potential to improve the quality of health care delivery, although results from high quality studies have been mixed. We conducted a systematic review to evaluate whether certain features of prescribing decision support systems (RxCDSS) predict successful implementation, change in provider behaviour, and change in patient outcomes.MethodsA literature search of Medline, EMBASE, CINAHL and INSPEC databases (earliest entry to June 2008) was conducted to identify randomized controlled trials involving RxCDSS. Each citation was independently assessed by two reviewers for outcomes and 28 predefined system features. Statistical analysis of associations between system features and success of outcomes was planned.ResultsOf 4534 citations returned by the search, 41 met the inclusion criteria. Of these, 37 reported successful system implementations, 25 reported success at changing health care provider behaviour, and 5 noted improvements in patient outcomes. A mean of 17 features per study were mentioned. The statistical analysis could not be completed due primarily to the small number of studies and lack of diversity of outcomes. Descriptive analysis did not confirm any feature to be more prevalent in successful trials relative to unsuccessful ones for implementation, provider behaviour or patient outcomes.ConclusionWhile RxCDSSs have the potential to change health care provider behaviour, very few high quality studies show improvement in patient outcomes. Furthermore, the features of the RxCDSS associated with success (or failure) are poorly described, thus making it difficult for system design and implementation to improve.

Changing roles and responses of health care workers in HIV treatment and care

A key limiting factor in the scale up and sustainability of HIV care and treatment programmes is the global shortage of trained health care workers. This paper discusses why it is important to move beyond conceptualising health care workers simply as 'inputs' in the delivery of HIV treatment and care, and to also consider their roles as partners and agents in the process of health care. It suggests a framework for thinking about their roles and responses in HIV care, considers the current evidence base, and concludes by identifying key areas for future research on health care workers' responses in HIV treatment and care in low and middle income settings.

Internet-Based Health Information Seeking Among Low-Income, Minority Seniors Living in Urban Residential Centers

This article discusses the results of an exploratory study designed to measure low-income, minority elderly adults Internet-based health information—seeking activities. The study is a part of a program designed to teach residents, living in high-rise urban communities, how to use the Internet to locate health information. By teaching minority seniors how to locate Internet-based health information, it is hoped that they will seek more information regarding their health conditions, treatments, and medications. The results of the study draw five inferences regarding participant's health information—seeking behavior: The retrieved information helps the elderly understand their health problems; retrieved information will not lead the elderly to engage in self-care, nor will it engage them enough to change health care providers; retrieved information can change elderly eating and exercise patterns, and retrieved information can affect the treatments the elderly receive for their illnesses.

Separate And Unequal: Racial Segregation And Disparities In Quality Across U.S. Nursing Homes

We describe the racial segregation in U.S. nursing homes and its relationship to racial disparities in the quality of care. Nursing homes remain relatively segregated, roughly mirroring the residential segregation within metropolitan areas. As a result, blacks are much more likely than whites to be located in nursing homes that have serious deficiencies, lower staffing ratios, and greater financial vulnerability. Changing health care providers' behavior will not be sufficient to eliminate disparities in medical treatment in nursing homes. Persistent segregation among homes poses a substantial barrier to progress.

Nurses' performance on hospital discharge: patients' point of view

OBJECTIVE: To know the hospital discharge process in place and the nurses' performance in preparing patients for discharge. METHODS: A descriptive study using semi-structured interviews was used to collect data from 43 patients of medical-surgical units of a major teaching hospital in the state of São Paulo, Brazil. RESULTS: The majority of patients (83.72%) received tailored discharge instructions. However, a great number of patients (72.08%) reported discharge instructions were not given by nurses. Almost a half of patients (48.84%) reported that discharge instructions were given by their physicians. CONCLUSION: The findings of this study provide insights to improve the educational process of new nurses and their preparation to provide effective discharge instructions. There is also a need to design and implement a hospital discharge process that promotes the participation of interdisciplinary health care providers who are involved in patient clinical care. This discharge process might be an effective way to change health care providers' attitude toward discharge instructions.

Changing Health Care Providers: A Study of Midlife Women

Changing Health Care Providers: A Study of Midlife Women