Clinic Implementation Research Articles

Diabetes telemedicine clinic implementation during the COVID-19 virus outbreak in Saudi Arabia

Background: Saudi Arabia implemented a nationwide lockdown to slow the spread of the COVID-19 after a global pandemic has been declared by the World Health Organization. Diabetes patients are one of the most vulnerable chronic illness groups to the complications of COVID-19 virus, thus the necessary to implement a tele-medicine clinic during the lockdown. Methods: A cross-sectional observational study, the study was done during the period from October to December 2020. We used convenience sampling to select participants who attended the clinics of the Diabetes Care Center at King Salman Hospital, Riyadh, Saudi Arabia. A total of 375 patients participated in the study. Results: The study included 375 participants around 60% were female participants. The age of almost one-third of them (33.9%) ranged between 51 and 60 years. Most of the participants were type 2 diabetic patients (85.3%), and lived in Riyadh city (97.6%). Vast majority of participants (99.5%) were follow-up patients and reported telemedicine visit by physicians (98.9%). Patients’ satisfaction questions showed that majority of the participants either strongly agreed or agreed with the statements that they were satisfied with the quality of the audio during the virtual visit (92%), use of telemedicine was essential in maintaining health during the COVID-19 outbreak (90.1%), the quality of the medical care provided during the virtual visit (88.3%), the clarity of the management plan discussed with the heath care practitioner during the virtual visit (87.7%), the tele-medicine visit was as good as a regular in person visit (81.5%). Also, majority of the participants recommend making diabetes tele-medicine clinic as an available option for patients with diabetes after the COVID-19 outbreak is over (81.5%). Conclusion: The COVID-19 pandemic has urged the transition from in person clinical visits to tele-medicine clinics and showed that it is feasible and effective to have the option of tele-medicine for diabetes clinics in Saudi Arabia. The majority of diabetic patients reported high levels of satisfaction with the tele-medicine clinic.

Nurse Practitioner-Managed Clinic Reduces Emergency Department Visits for Parents of Children With Problematic Gastrostomy Tubes

Background Gastrostomy tube (G-tube) placement is commonly performed on pediatric patients but has high rates of emergency department (ED) utilization. We hypothesized that a nurse-practitioner-driven G-tube clinic would reduce ED visits and complications and improve provider and patient satisfaction. Methods After institutional review board approval, a retrospective chart review was conducted for all patients < 18 years old undergoing G-tube placement between January 2014 and June 2018. Data collected included demographics, indication, and type of G-tube as well as ED visits, clinic visits, and outcomes up to 1-year postoperative. Surveys were distributed to providers and parents to assess attitudes toward the clinic. Results There was a decrease in the number of physician clinic visits, but there was no difference in overall 30- or 90-day ED visits after institution of the G-Tube Clinic. In the cohort of patients who had problematic G-tube-related problems, such as granulation, plugged tube, or tube dislodgement, creation of the G-Tube Clinic significantly reduced 30-day (0.37 vs. 0.07, p = .0008), 90-day (0.27 vs. 0.73, p = .0031), and 1-year (0.6 vs. 1.18, p = .014) ED visits. Surgeon and patient satisfaction were improved with clinic implementation. Conclusions Implementation of a nurse-practitioner-managed clinic resulted in reduction in 30-day, 90-day, and 1-year ED visits among patients with gastrostomy issues and is associated with high levels of patient and provider satisfaction.

Enhancing Value-Based Care With a Walk-in Clinic: A Primary Care Provider Intervention to Decrease Low Acuity Emergency Department Overutilization.

BackgroundEmergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems.MethodsA retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic.ResultsOver the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902.ConclusionExtended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.

1034. Patient Perspectives on Implementation of a Long-Acting Injectable Antiretroviral Therapy Regimen in HIV US Healthcare Settings: Interim Results from the CUSTOMIZE study

BackgroundCabotegravir and rilpivirine long-acting (CAB+RPV LA) administered by monthly injection demonstrated non-inferiority compared to standard daily oral antiretroviral therapy (ART) at 48 weeks. This novel treatment offers a less frequent dosing alternative to daily oral pills but requires more frequent clinic visits. Patient perspectives on implementation of CAB + RPV LA in US healthcare settings were evaluated in an innovative Hybrid III implementation-effectiveness study (CUSTOMIZE).MethodsThis single-arm study enrolled virologically suppressed patients to receive monthly CAB+RPV LA across eight diverse US clinics. Patients were surveyed at Baseline (BL) prior to the first injection and at Month 4 (M4) prior to the fourth injection to evaluate clinic implementation of CAB+RPV LA, including Acceptability of Intervention (AIM) and Intervention Appropriateness (IAM) Measures. Subgroups were compared with Fisher’s exact test.ResultsA total of 109 and 105 patients completed BL and M4 surveys, respectively, and were 87% male; 59% Caucasian and 35% African American; 27% Hispanic/Latino; mean age 39 years (range 20-65). At BL, 33% reported hiding their oral ART from others, 22% reported problems remembering to take daily ART (female 43% > male 19%, p< 0.05), while 47% reported no problems with daily ART (male 51% > female 21%, p< 0.05). Patient “interest in a more convenient treatment option” (83%) was a top reason for choosing CAB+RPV LA treatment. Acceptability and appropriateness of CAB+RPV LA were high at BL and M4 (Figures). At M4, 84% of patients reported that monthly clinic visits were very/extremely acceptable and 66% reported no logistical challenges to clinic administered CAB+RPV LA. Injection pain/soreness was the most common worry at BL (58%); at M4, 28% reported injection pain/soreness as a concern. For Months 2-4, 95% of injections were within a +/-7-day dosing window (5% were early, -7 to -14 days). No patients missed an injection or required oral bridging.Figure 1. Acceptability of CAB+RPV LA: AIM Figure 2: Appropriateness of CAB+RPV LA: IAM ConclusionMost patients found CAB+RPV LA to be acceptable and appropriate, and a majority reported monthly appointments were highly acceptable. Initial implementation data suggest CAB+RPV LA is a convenient, appealing alternative treatment option for patients, with few reported logistical challenges.DisclosuresCindy Garris, MSPH, GlaxoSmithKline (Other Financial or Material Support, Stockholder)ViiV Healthcare (Employee) Ronald D’Amico, DO, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Paul Wannamaker, BA, ViiV Healthcare (Employee) Nobuhle Mpofu, MS, GlaxoSmithKline (Employee, Shareholder) Colleen A. McHorney, PhD, Evidera (Employee) Sonal Mansukhani, PhD, MBA, BS Pharm, Evidera (Employee) Maggie Czarnogorski, MD, MPH, ViiV Healthcare (Employee)

Characterizing clinics with differential changes in the screening rate in the Colorectal Cancer Control Program of the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention (CDC) funds the Colorectal Cancer Control Program (CRCCP) to increase colorectal cancer (CRC) screening rates in primary care clinics by implementing evidence-based interventions (EBIs). This study examined differences in clinic characteristics and implementation efforts among clinics with differential changes in screening rates over time. CRCCP clinic data collected by the CDC were used. The outcome was the clinic status (highest quartile [Q4] vs lowest quartile [Q1]), which was based on the absolute screening rate change between the first and second program years. Five clinic characteristic variables and 12 clinic-level CRCCP variables (eg, EBIs) were assessed in bivariable analyses, and logistic regression was used to determine significant predictors of the outcome. Each group included 78 clinics (N = 156). Clinics with a Q4 status saw a 14.9 percentage point increase in the screening rate, whereas clinics with a Q1 status experienced a 9.1 percentage point decline. Q4s were more likely than Q1s to have a CRC champion, implement 4 EBIs versus fewer EBIs, implement at least 1 new EBI, and increase the number of implemented EBIs. The adjusted odds of Q4 status were 5.3 times greater (95% confidence interval [CI], 1.9-14.9) if a clinic implemented an additional EBI. The adjusted odds of Q4 status increased to 7.1 (95% CI, 2.2-23.1) if a clinic implemented 2 to 4 additional EBIs. Implementing new EBIs or enhancing existing ones improves CRC screening rates. Additionally, clinics with lower screening rates had greater rate increases and may have benefited more from the CRCCP.

Improving Medication Adherence in an ACO Primary Care Office With a Pharmacist­Led Clinic: A Report From the ACORN SEED

Background: As health care moves into the era of value-based medicine, both ambulatory and acute settings are being held accountable for the quality of care provided to patients. Previous studies have shown improved clinical outcomes through medication therapy management (MTM) due to improved medication adherence. Objective: The purpose of this study is to assess the effects of a pharmacist-led MTM clinic in an accountable care organization (ACO) affiliated primary care office on adherence to renin-angiotensin system (RAS) antagonists, diabetic medications, and/or statin medications reported through Healthcare Effectiveness Data and Information Set (HEDIS) Medicare Star Ratings. Methods: In this retrospective cohort study, data were collected via chart review of pharmacist-led MTM patient interviews and follow-ups between October 2015 and April 2017. Eligible patients were Humana HMO Medicare beneficiaries, with at least one chronic disease state, for which they were treated with a RAS antagonist, statin, or diabetic medication. The primary outcome of this investigation was a change in Star Rating scores for medication adherence to RAS antagonists, diabetic medications, and statins from pre- and postpharmacist MTM intervention. Results: A total of 102 patients were referred to the MTM clinic. Out of these, 32 had a follow-up visit, resulting in a total of 25 interventions. One year prior to MTM clinic implementation, most Star Ratings were consistently 3 (out of 5) for RAS antagonists, diabetic medications, and statins. Postintervention, ratings increased to 4 or 5 across these categories. Conclusion: Implementing a pharmacist-led MTM clinic in the ACO primary care setting improves Medicare Star Ratings in patients with chronic conditions.

Assessing the utilization and impact of a newly established outpatient parenteral antimicrobial therapy (OPAT) program.

Outpatient parenteral antimicrobial therapy (OPAT) is a safe and effective alternative to hospitalization for many patients with infectious disease. The objective of this study was to describe the experience with a newly established formal OPAT program at a Canadian academic centre. We conducted a retrospective cohort study including all patients referred to the OPAT clinic between July 2016 and June 2017 and a contemporary cohort of patients who received home parenteral therapy without clinic referral. A quasi-experimental design was used to assess the impact of the clinic on patient outcomes compared with a pre-intervention cohort of patients from 2012 to 2013. Between July 2016 and June 2017, 334 patients were referred to the OPAT clinic; 33% of the patients visited the emergency department (ED), and 21% required readmission within 60 days. Compared with the clinic patients, urinary tract infection diagnoses were more common among the 39 contemporary patients who were treated with home parenteral antibiotics without OPAT clinic referral (51% versus 4%, respectively; p < 0.001) and treatment durations were shorter (median 10 days versus 42 days; p < 0.001). Compared with a pre-intervention cohort, OPAT clinic implementation was associated with a trend toward decreased ED visits (33% versus 43%; p = 0.07). On multivariable analysis, this translated to an overall adjusted odds ratio of 0.64 (95% CI 0.40 to 1.04, p = 0.07) for readmission and ED visits. The OPAT clinic served a high volume of patients in its first year of operation and may be helpful in reducing unfavourable patient outcomes.

MP52: Effectiveness of an outpatient parenteral antibiotic therapy clinic for adults with non-purulent cellulitis

Introduction: Emergency department (ED) patients with cellulitis that are treated with intravenous (IV) antibiotics may be eligible for outpatient parenteral antibiotic therapy (OPAT). The primary objective of this study was to determine whether the implementation of an OPAT clinic results in decreased hospitalization and return ED visits for patients treated with IV antibiotics. Methods: We conducted a before-after implementation study involving adults (age &gt;=18 years) that presented to two tertiary care EDs with cellulitis and were treated with IV antibiotics. The intervention was referral to an infectious disease physician within one week of the index ED visit at the newly created OPAT clinic. The primary outcomes were hospital admission and return ED visits within 14 days. Secondary outcomes were treatment failure (admission after 48 hours of OPAT) and adverse events (e.g. vomiting, diarrhea). We conducted an interrupted time series analysis from January to December both pre-intervention (2013) and post-intervention (2015), with 24 monthly data points. The year of clinic implementation (2014) was considered a transition period. A segmented non-linear regression autoregressive error model was used to aggregate the monthly data to evaluate the effectiveness of the intervention. Results: A total of 1,666 patients met inclusion criteria: 858 pre-intervention (mean age 59 years, 53.1% male) and 808 post-intervention (mean age 62 years, 54.5% male). Hospitalization rates were not significantly higher one year after clinic implementation (p = 0.53) although there was a non-statistically significant gradual increase of 0.8% per month (95%CI -0.3% to 1.9%). One year after introduction of the OPAT clinic, return ED visits were significantly lower (change in intercept -24.4%, 95%CI -34.2% to -14.6%; p &lt; 0.001), followed by an additional drop of 1.4% per month (95%CI -2.1% to -0.6%; p = 0.002). By the end of the study, return visits were 40.7% lower (95%CI 25.6% to 55.9%) than if the intervention had not been introduced. Treatment failure rates were &lt;2% and adverse events were &lt;5% in both groups. Conclusion: Implementation of an OPAT clinic significantly reduced return ED visits for cellulitis, which is critically important given the current ED overcrowding crisis. There was no significant change in hospital admission rates. There were low rates of treatment failures and adverse events. An OPAT clinic should be considered to reduce ED crowding while maintaining safe patient care.

Key Lessons Learned in the Strategic Implementation of the Primary Care Collaborative Memory Clinic Model: A Tale of Two Regions.

Primary care collaborative memory clinics (PCCMCs) address existing challenges in dementia care by building capacity to meet the needs of persons living with dementia within primary care. This paper describes the strategic implementation of the PCCMC care model in two regions within Ontario. Evaluation of this initiative included the completion of individual interviews (N = 32) with key informants to identify impacts associated with the PCCMCs and tracking of all referrals and assessments completed in the first nine months of clinic implementation. The qualitative analysis of interview transcripts generated five major themes: (1) earlier identification of dementia and intervention; (2) increased capacity for dementia care within primary care; (3) better patient and caregiver experience with care; (4) improved continuity, integration and coordination and improved care; and (5) system efficiencies. Across both regions, 925 patients were referred to PCCMCs, of which 631 (68%) had been assessed during the evaluation period. Strategic, regional implementation of PCCMCs provides a significant opportunity to support better integrated and coordinated dementia care.

Confronting the Crisis of Comorbid Alcohol Use Disorder and Alcohol-Related Liver Disease With a Novel Multidisciplinary Clinic

Alcohol-related liver disease (ALD) is prevalent and deadly and increasingly affects younger people and women. No single discipline is adequately equipped to manage its biopsychosocial complexity. Depict the scope of the ALD problem, provide a narrative review of other integrated care models, share our experience forming and maintaining a multidisciplinary ALD clinic for over a year, and provide recommendations for replication elsewhere. Critical evaluation of clinic implementation and its first year of operation. The clinical rationale for multidisciplinary ALD treatment is clear and supported by the literature. Such models are feasible although surprisingly rare and vulnerable to various surmountable challenges. Successful ALD clinics must be built by teams with solid personal and professional relationships, supported by institutional leadership, and must use a new kind of multidisciplinary paradigm and training. Consultation-liaison psychiatry is uniquely positioned to lead future efforts in the care and study of ALD.

23 Implementation of a Substance Use Disorder Bridge Clinic

Despite the availability of substance use disorder (SUD) treatment programs, many patients have difficulty accessing treatment partly due to long wait times. In order to facilitate timely linkage to treatment, our health system implemented a rapid access, low-barrier SUD clinic with the goal of providing prompt initial treatment (including buprenorphine on-demand) and then transitioning to longitudinal care once possible, regardless of insurance status or current substance use. The clinic, which is located close to the ED inside the hospital, opened in April 2018. The goal of this study is to describe the clinic implementation and outcomes for patients treated in the first year of the clinic. This was a retrospective analysis of patients seen at the clinic between April 2018 and March, 2019. Clinic staff includes a medical provider who can prescribe medication for addiction treatment (MAT), a resource specialist who connects patients to housing, phone service, ID cards and other social services, and recovery coaches, who use their own lived experience to coach other patients through their recovery. The data were obtained at the clinic as part of a quality improvement project to monitor the progress of patients treated in the clinic. IRB approval was obtained to use the dataset for this research. In one year, there were 325 patients referred to the clinic and 242 patients (74.8%) who had at least one visit to the clinic. Top sources of referral were: inpatient wards (n=111, 34.2%), emergency department (n=68, 20.9%), primary care (n=50, 15.4%), or other clinic referral (n=55, 16.9%). The patients were 68.3% (n=222) male, with a mean age of 43.4 (SD 11.9) years. 66% of patients had opioid use disorder, 39% had alcohol use disorder, and 31% had polysubstance use. Of the 242 patients who made it to at least one appointment, 131 patients (54.1%) are still active in the clinic, 85 (35.1%) have been bridged to other facilities and 26 (10.7%) were lost to follow-up. Amongst patients treated for opioid use disorder at the clinic, 142 (93%) were taking buprenorphine, 7 (5%) were taking methadone, and 4 (3%) received extended-release naltrexone. For 98 patients who have data 6 months prior and 6 months post clinic referral, ED visits in our health system decreased by 45% (from 276 before to after 151) and hospital admissions in our health system decreased by 37% (from 153 before to 96 after). Creation of a low-barrier, rapid-access, hospital-based substance use disorder bridge clinic is feasible. Outcomes are promising, with high rates of retention and linkage to treatment, and decreased rate of subsequent ED utilization and hospitalization. Keys to success are a multidisciplinary team, harm reduction model, and support from the health system.

Partnerships for improving dementia care in primary care: Extending access to primary care‐based memory clinics in Ontario, Canada

In Ontario, Canada, the Primary Care Collaborative Memory Clinic (PCCMC) model of dementia care provides a team-based assessment and management service that has demonstrated increased capacity for dementia care at the primary care level. PCCMCs are established following completion of a multi-faceted memory clinic training programme. Evidence of the success of this care model has been demonstrated primarily in practice settings with integrated interprofessional healthcare providers (HCPs). Desire to implement PCCMCs in less-resourced family practice settings without integrated interprofessional HCPs has resulted in partnerships with community agencies and services to create the multifaceted teams needed for this care model. The purpose of this study was to describe the key lessons learned in the development and implementation of 18 PCCMCs in primary care practice models without integrated interprofessional HCPs. Mixed methods included tracking of clinic referrals, pre- (N=122) and post- (N=71) training surveys to assess practice changes and factors facilitating and challenging clinic implementation. Interviews were conducted with 40 team members to identify key lessons learned. Key enablers were access to training, organisational/ management and care provider support, availability of infrastructure supports and clinic coordination. Data were collected between January 2012 and January 2017. PCCMCs were challenged by a lack of sustainable funding, inadequate infrastructure support, competing priorities, maintaining adequate communication among team members, and coordinating multiple schedules. Suggestions to support longer term sustainability were identified, many addressing identified challenges such as securing sustainable funding, and ensuring partners understand the importance of their role and succession planning. This study demonstrated that by establishing community partnerships and leveraging existing community resources, the PCCMC model is generalisable to multiple family practice settings including those without integrated interprofessional staff. Lessons learned can inform the development of interventions for complex chronic conditions requiring interprofessional support in primary care.

Implementation of an ICU Recovery Clinic at a Tertiary Care Academic Center.

Objectives:Post-ICU clinics may facilitate the care of survivors of critical illness, but there is a paucity of data describing post-ICU clinic implementation. We sought to describe implementation of our ICU recovery clinic, including an assessment of barriers and facilitators to clinic attendance.Design:Adults admitted to the medical ICU of a large tertiary care academic hospital with shock and/or respiratory failure requiring mechanical ventilation were screened for participation in a newly formed ICU recovery clinic. Participant selection and attendance rates were tracked. Reasons for nonattendance were assessed by phone call in a subset of patients.Setting:A newly formed ICU recovery clinic of a large tertiary care academic hospital.Patients:All patients admitted to the medical ICU were screened.Interventions:ICU recovery clinic appointments were scheduled for all eligible patients. A subset of nonattenders were called to assess reasons for nonattendance.Measurements and Main Results:Over 2 years, we admitted 5,510 patients to our medical ICU. Three hundred sixty-two were screened into the recovery clinic. One-hundred sixty-six were not scheduled for clinic; major reasons included discharge to hospice/death in the hospital (n = 55) and discharge to a facility (n = 50). One-hundred ninety-six patients were scheduled for a visit and of those, 101 (52%) arrived to clinic. Reasons for nonattendance in a surveyed subset of nonattenders included patient’s lack of awareness of the appointment (50%, n = 9/18), financial concerns (17%, n = 3/18), and transportation difficulty (17%, n = 3/18).Conclusions:ICU recovery clinics may address the needs of survivors of critical illness. Barriers to clinic attendance include high mortality rates, high rates of clinic appointment cancelations and nonattendance, and discharge to locations such as skilled nursing facilities or long-term acute care hospitals. Improved communication to patients about the role of the clinic may facilitate attendance and minimize canceled appointments.

Models of Pediatric Palliative Oncology Outpatient Care-Benefits, Challenges, and Opportunities.

Although the bulk of current pediatric palliative care (PPC) services are concentrated in inpatient settings, the vast majority of clinical care, symptom assessment and management, decision-making, and advance care planning occurs in the outpatient and home settings. As integrated PPC/pediatric oncology becomes the standard of care, novel pediatric palliative oncology (PPO) outpatient models are emerging. The optimal PPO model is unknown and likely varies on the basis of institutional culture, resources, space, and personnel. We review five institutions' unique outpatient PPO clinical models with their respective benefits and challenges. This review offers pragmatic guidance regarding PPO clinic development, implementation, and resource allocation. Specific examples include a floating clinic model, embedded disease-specific PPC experts, embedded consultative or trigger-based supportive care clinics, and telehealth clinics. Organizations that have overcome personnel, funding, and logistical challenges can serve as role models for centers developing PPO clinic models. In the absence of a one-size-fits-all model, pediatric oncology and PPC groups can select, tailor, and implement the model that best suits their respective personnel, needs, and capacities. Emerging PPO clinics must balance the challenges and opportunities unique to their organization, with the goal of providing high-quality PPC for children with cancer and their families.

099 Do clinical nurse specialist led stroke follow-up clinics reduce post-stroke hospital readmissions and recurrent vascular events?

IntroductionPost-discharge stroke follow-up clinics have been associated with improved outpatient care and reduced readmission. Pre-2014 there was no consistent follow-up care offered at Wellington Hospital. Our aim was to determine whether the establishment of a clinical nurse specialist (CNS) follow-up clinic reduced the readmission 12-monthrate.MethodsThis is a sequential comparison of patient admitted with stroke one year prior and one year after the clinic was established in 2013. The primary outcome was hospital 12-month hospital readmission rate; main secondary outcome was recurrent vascular event. Patients were identified from the hospital discharge records and underwent detailed electronic chart review. Results were adjusted for differences in baseline characteristics.ResultsWe identified 874 patients; 439 pre- and 435 post-nurse clinic implementation. There was no significant difference between the one-year readmission rate after the establishment of the stroke follow up clinic (adjusted OR=1.06; 95% CI, 0.85–1.64; p=0.804) and no difference in recurrent composite vascular events at one-year (adjusted OR=1.20; 95% CI, 0.68–2.11; p=0.528). The median (IQR) time to follow-up to clinic after discharge was 85 (63–98.5) days. There was a trend towards a reduction in vascular events when limiting the analysis to patients who actually attended clinic, but this trend disappeared when adjusting for baseline inter-group differences.ConclusionsThere was no reduction in the one-year hospital readmission or vascular event recurrence rate for patients with stroke following the establishment of a nurse specialist led stroke follow up clinic. Earlier timed follow-up and the psychosocial value offered by these clinics requires further evaluation.

Closed-loop electronic referral to SmokefreeTXT for smoking cessation support: a demonstration project in outpatient care.

Too few smokers who present for outpatient healthcare receive evidence-based interventions to stop smoking. Referral to nationally available smoking cessation support may enhance tobacco intervention reach during healthcare visits. This study evaluated the feasibility of outpatient electronic health record (EHR)-enabled, closed-loop referral (eReferral) to SmokefreeTXT, a National Cancer Institute text message smoking cessation program. SmokefreeTXT eReferral for adult patients who smoke was implemented in a family medicine clinic and an allergy and asthma clinic in an integrated Midwestern healthcare system. Interoperable, HIPAA-compliant eReferral returned referral outcomes to the EHR. In Phase 1 of implementation, clinicians were responsible for eReferral; in Phase 2 this responsibility shifted to Medical Assistants and/or nurses. EHR data were extracted to compute eReferral rates among adult smokers and compare demographics among those eReferred versus not referred. SmokefreeTXT data were used to compute SmokefreeTXT enrollment rates among those eReferred. Descriptive analyses of clinic staff surveys assessed implementation context and staff attitudes toward and adaptations of eReferral processes. During clinician implementation, 43 of 299 adult smokers (14.4%) were eReferred. During medical assistant (MA) implementation, 36 of 401 adult smokers (9.0%) were eReferred. Overall, among those eReferred, 25.7% completed SmokefreeTXT enrollment (3.1% of patients eligible for eReferral). Staff survey responses indicated that eReferral was efficient and easy. eReferral rates and relevant attitudes varied meaningfully by clinic. Thus, interoperable eReferral via outpatient EHR to SmokefreeTXT is feasible and acceptable to clinic staff and enrolls roughly 3.0% of smokers. Clinic context and implementation approach may influence reach.

Improving Timeliness of Oncology Assessment and Cancer Treatment Through Implementation of a Multidisciplinary Lung Cancer Clinic.

Timely lung cancer care has been associated with improved clinical outcomes and patient satisfaction. We identified improvement opportunities in lung cancer management pathways at Kingston Health Sciences Centre. Quality improvement strategies led to the implementation of a multidisciplinary lung cancer clinic (MDC). We set an outcome measure of decreasing the time from diagnosis to first cancer treatment by 10 days within 6 months of clinic implementation. We implemented a weekly MDC that involved respirologists, medical oncologists, and radiation oncologists at which patients with new lung cancer diagnoses were offered concurrent oncology consultation. We used Plan-Do-Study-Act cycles to guide our improvement initiatives. A total of five Plan-Do-Study-Act cycles spanned 14 months and consisted of an MDC pilot clinic, large-scale MDC launching, debriefing meetings, and clinic expansion. Pre-MDC data were analyzed retrospectively to establish baseline and prospectively for improvement. Statistical Process Control XmR(i) charts were used to report data. Since MDC initiation, 128 patients have been seen in 34 MDC clinics (3.8 patients per clinic). Mean days from diagnosis to first oncology assessment decreased from 12.4 days to 3.9 days, and mean days from diagnosis to first cancer treatment decreased from 39.5 to 15.0 days, both of which demonstrated special cause variation. Time to assessment and treatment improved for patients with every stage of lung cancer and for both small-cell and non-small-cell subtypes. MDC shortens the time from lung cancer diagnosis to oncology assessment and treatment. Time to treatment improved more than time to oncology assessment, which suggests the improvement is related to benefits beyond faster oncology assessment.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas

BackgroundThe Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics’ Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention.MethodsThe study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013–2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention.ResultsMean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study.ConclusionsThe development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

Billing and Volunteers Substantially Reduced School-Located Influenza Vaccination Costs, 2 Oregon Counties, 2010-2011.

After the 2009 pandemic influenza seasons, the financial sustainability of school-located vaccination (SLV) clinics drew much attention. This study estimated and compared the labor costs of SLV clinics and reimbursements for influenza vaccinations for students attending 5 schools in 2 Oregon counties during 2010-2011. Using a biweekly, Web-based survey, staff and volunteers prospectively tracked the time they spent on SLV clinic planning, implementation, and billing. They also tracked claims submitted and reimbursements by payment source. We report labor hours and associated costs for implementing school-based vaccination clinics; number of claims submitted and the reimbursement rate; and total and net costs. In county A, 260 doses were administered at a total cost of $5009 and received $3620 in payment. For county B, 165 doses were administered at a cost of $5598 and received $3807 in payments. With billing, the net cost per dose decreased from $19.74 to $8.57 and $38.08 to $16.17, for county A and county B, respectively. Reimbursements reduced cost per dose by 48% across SLV clinics across both Oregon counties. Local health departments can bill local health insurers to offset costs for implementing school-based vaccination clinics. Efforts to set up billing processes require dedicated billing staff who can effectively manage claims submission processes with multiple health insurers.

Barriers and Facilitators When Implementing Web-Based Disease Monitoring and Management as a Substitution for Regular Outpatient Care in Pediatric Asthma: Qualitative Survey Study.

BackgroundDespite their potential benefits, many electronic health (eHealth) innovations evaluated in major studies fail to integrate into organizational routines, and the implementation of these innovations remains problematic.ObjectiveThe purpose of this study was to describe health care professionals’ self-identified perceived barriers and facilitators for the implementation of a Web-based portal to monitor asthmatic children as a substitution for routine outpatient care. Also, we assessed patients’ (or their parents) satisfaction with this eHealth innovation.MethodsBetween April and November 2015, we recruited 76 health care professionals (from 14 hospitals). During a period of 6 months, participants received 3 questionnaires to identify factors that facilitated or impeded the use of this eHealth innovation. Questionnaires for patients (or parents) were completed after the 6-month virtual asthma clinic (VAC) implementation period.ResultsMajor perceived barriers included concerns about the lack of structural financial reimbursement for Web-based monitoring, lack of integration of this eHealth innovation with electronic medical records, the burden of Web-based portal use on clinician workload, and altered patient-professional relationship (due to fewer face-to-face contacts). Major perceived facilitators included enthusiastic and active initiators, a positive attitude of professionals toward eHealth, the possibility to tailor care to individual patients (“personalized eHealth”), easily deliverable care according to current guidelines using the VAC, and long-term profit and efficiency.ConclusionsThe implementation of Web-based disease monitoring and management in children is complex and dynamic and is influenced by multiple factors at the levels of the innovation itself, individual professionals, patients, social context, organizational context, and economic and political context. Understanding and defining the barriers and facilitators that influence the context is crucial for the successful implementation and sustainability of eHealth innovations.