Enhance Patient Engagement Research Articles

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Improving Cardiovascular Drug and Device Development and Evidence Through Patient-Centered Research and Clinical Trials: A Call to Action From the Value in Healthcare Initiative's Partnering With Regulators Learning Collaborative.

The pipeline of new cardiovascular drugs is relatively limited compared with many other clinical areas. Challenges causing lagging drug innovation include the duration and expense of cardiovascular clinical trials needed for regulatory evaluation and approvals, which generally must demonstrate noninferiority to existing standards of care and measure longer-term outcomes. By comparison, there has been substantial progress in cardiovascular device innovation. There has also been progress in cardiovascular trial participation equity in recent years, especially among women, due in part to important efforts by Food and Drug Administration, National Institutes of Health, American Heart Association, and others. Yet women and especially racial and ethnic minority populations remain underrepresented in cardiovascular trials, indicating much work ahead to continue recent success. Given these challenges and opportunities, the multistakeholder Partnering with Regulators Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University, identified how to improve the evidence generation process for cardiovascular drugs and devices. Drawing on a series of meetings, literature reviews, and analyses of regulatory options, the Collaborative makes recommendations across four identified areas for improvement. First, we offer strategies to enhance patient engagement in trial design, convenient participation, and meaningful end points and outcomes to improve patient recruitment and retention (major expenses in clinical trials). Second, new digital technologies expand the potential for real-world evidence to streamline data collection and reduce cost and time of trials. However, technical challenges must be overcome to routinely leverage real-world data, including standardizing data, managing data quality, understanding data comparability, and ensuring real-world evidence does not worsen inequities. Third, as trials are driven by evidence needs of regulators and payers, we recommend ways to improve their collaboration in trial design to streamline and standardize efficient and innovative trials, reducing costs and delays. Finally, we discuss creative ways to expand the minuscule proportion of sites involved in cardiovascular evidence generation and medical product development. These actions, paired with continued policy research into better ways to pay for and equitably develop therapies, will help reduce the cost and complexity of drug and device research, development, and trials.

21-OR: Implementation of an Intensive Telehealth Intervention for Rural Patients with Uncontrolled Diabetes

Background: In rural areas, lack of access to specialty care and intensive self-management programs may perpetuate poor diabetes outcomes. Telehealth presents an opportunity to extend specialized diabetes care to rural areas, but may be difficult to implement in routine practice. We examined rural implementation of an intensive telehealth intervention designed to leverage existing Veterans Health Administration (VHA) Home Telehealth (HT) infrastructure for patients with uncontrolled type 2 diabetes despite receiving routine care. Methods: Advanced Comprehensive Diabetes Care (ACDC) is a 6-month telehealth intervention for patients with poor glycemic control (varies by site, typically ≥8.5%), established as effective in a prior randomized trial. ACDC combines telemonitoring, self-management support, and clinician-guided medication management, and is delivered by clinical HT nurses using standard HT equipment. During 2017-2019, we implemented and evaluated ACDC at 5 rural VHA sites with guidance from the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Results: From 2017-2019, 30-100% of eligible patients at each site were enrolled in ACDC, for a total of 125 patients (94% male, 89% white, 71% classified as rural/highly rural). Across sites, mean HbA1c improved from 9.25% at baseline to 7.89% at 6 months (-1.36%, 95% CI: -1.61,-1.11; p<0.001), a benefit that persisted at 12 (-1.22%, 95% CI: -1.48,-0.97; p<0.001) and 18 months (-1.07%, 95% CI -1.40,-0.73; p<0.001). Implementation at each site was acceptable, with an average of 8-10 of 12 scheduled ACDC calls completed. Qualitatively, ACDC enhanced patient engagement and awareness of glycemic control, while moderately increasing workload for providers. Conclusions: When strategically designed to use existing infrastructure, intensive telehealth interventions are conducive to implementation and produce sustained improvements in glycemic control among rural patients. Disclosure E.A. Kobe: None. A. Lewinski: None. S. Danus: None. E.L. Sidoli: None. B. Greck: None. L.C. Horne: None. D. Saxon: None. S.D. Shook: None. L.E. Aguirre: None. C. Evenson: None. C.S. Elizagaray: None. G.L. Jackson: None. H.B. Bosworth: Board Member; Self; Preventric Diagnostic. Consultant; Self; Abbott, Medicines Company, Novartis Pharmaceuticals Corporation. Research Support; Self; improved patient outcomes, Novo Nordisk Foundation, Otsuka Pharmaceutical Co., Ltd., Otsuka Pharmaceutical Co., Ltd., Pharma foundation, Proteus Digital Health, Proteus Digital Health, Sanofi. D. Edelman: None. M. Crowley: None. Funding VA Office of Rural Health; Veterans Rural Health Resource Center-Iowa City (13366); National Center for Advancing Translation Sciences (TL1TR002555); VA Health Services Research and Development Service (IIR 16-213, 08-027); U.S. Department of Veterans Affairs (TPH 21-000); Durham Center of Innovation to Accelerate Discovery and Practice Transformation (CIN 13-410)

Preferences and motivational factors for the use of digital technology in real world oncology studies.

e14119 Background: Patient engagement and motivation during real world oncology studies can be challenging. Digital tools have proven to be effective in reducing patient burden and improving data collection and accuracy. Given the rapid advances in health technology, patient preferences and motivations for these tools are continually evolving. This study investigates preferences for digital technology use with smartphones and wearables, telehealth, and identifies motivational factors that would drive real world study compliance for daily symptom reporting. Methods: Patients (n = 50; 68% male) diagnosed with cancer answered questions via an anonymous online survey about their technology preferences. Results: Although the majority of the population uses smartphones (99%), few oncology patients use wearable technology such as a fitness watch (18%). Of those who do not own a fitness watch, 90% were willing to use the technology in a clinical study and share their data if a watch were provided to them. However, the majority of patients (74%) would prefer to use their own smartphone during a clinical study to answer questions and conduct video calls with the study doctor. For patients who currently visit their doctor in person (98%), almost half (48%) would prefer a remote alternative such as a video call for convenience, especially when in pain. Patients reported several factors that would encourage consistent daily reporting of study data. Out of 10 options, the most motivating factor was access to health information that would help manage their symptoms on a daily basis (92%). Subsequent factors of interest included in-app reminders (88%) and assurance that a doctor would review the reported data and contact them to discuss reported symptoms (94%). Conclusions: The global market for digital health is growing rapidly, and there is a strong preference from oncology patients to shift in-person engagement and reporting to digital platforms. Patients are also highly motivated by information about their own health. Designing real world studies to incorporate these preferences may result in enhanced patient engagement, improved compliance, and higher quality data.

Perceived barriers to healthcare utilization among Jordanian families: A family centered approach

AimThis study aimed to understand the barriers to health services utilization by Jordanian families. BackgroundAccess to quality healthcare services is a significant issue facing healthcare systems. Healthcare systems must identify and apply measures to overcome barriers that face utilizing health services and thus increase clients' satisfaction. MethodsA cross-sectional qualitative research design was used in this study. Semi-structured interviews were conducted with twenty-five families to elicit the model of health services barriers. ResultsThe analysis of the family interviews led to four main themes related to health services barriers: service system, structural/physical barriers, equipment and medication, and staff competency. This study would increase awareness about underserved populations that avoid seeking medical care. ConclusionPublic health efforts are required to increase awareness about the importance of contacting the healthcare system as early as possible. However, public health policy may require developing new initiatives that reduce these perceived barriers, such as enhancing communication skills among healthcare workers, increasing supervision and inspection of healthcare quality, and enhancing patient engagement by using phone calls and messages as appointment reminders and careful follow-up.

PMU128 PATIENT PREFERENCES AND MOTIVATION FOR USE OF DIGITAL TECHNOLOGY, TELEHEALTH, AND BYOD IN REAL WORLD STUDIES

To determine patient preferences for digital technology use, telehealth, and motivational factors that would drive real world study compliance for daily symptom reporting. Participants (N=762) answered questions via an anonymous online survey about their preferences. Although the majority of the population now uses smartphones (99.1%), only a few use wearable technology such as a fitness watch (31.8%). Of those who do not own a fitness watch, 96.5% were willing to use the technology and share their data if a watch were provided to them in a clinical study. However, the majority of participants (87.8%) prefer to use their own phone during a clinical study to answer questions and conduct video calls with the study doctor. For patients who currently visit their doctor in person, there is a strong desire (60.1%) for a remote alternative such as a video call for convenience. Participants reported several factors that would encourage them to enter study data on a daily basis. The most motivating factor out of 10 options would be to receive frequent health information that would help manage their symptoms on a daily basis (92.7%). Subsequent factors of interest include in-app reminders (91.3%) and assurance that a doctor is reviewing the data and will contact the patient to review the symptoms that were reported (90.4%). The global market for digital health is rapidly growing, and there is a strong appetite from patients to shift in-person engagement and sharing of information with study doctors to more digital platforms. Patients are also highly motivated by information about their own health. Designing real world studies to incorporate these preferences would result in enhanced patient engagement and potentially higher quality data.

Understanding the role of educational interventions on medication adherence in hypertension: A systematic review and meta-analysis

BackgroundMedication adherence among patients with hypertension has continued to be a challenge despite various educational interventions utilised in their care. The effect of the different educational methods on medication adherence in hypertension remains uncertain. ObjectivesTo examine the effect of educational interventions on improving medication adherence among patients with hypertension. MethodsA systematic search was conducted using EMBASE, MEDLINE, PsycINFO, CINHAL, PUBMED, HTA and Cochrane controlled trial registry from 1999 to 2019. Subgroup analysis was performed according to the various methods of educational intervention. ResultsTwelve studies identified from seven databases were interrogated. There was a low to moderate quality evidence to support the improvement of medication adherence with educational interventions. Verbal education had a small statistically significant effect d = 0.18 (95% CI 0.01–0.34, p < 0.04). No statistically significant difference was found between bimodal (verbal and printed) and multimodal (verbal, printed and electronic) educational interventions. Frequent contacts during patient education showed better outcomes of medication adherence. ConclusionsVerbal educational interventions can improve health literacy and consequent adherence to medication among individuals with hypertension. Frequent verbal educational interventions can enhance patient engagement, participation as well as promote medication literacy and adherence. Healthcare professionals should adopt innovative ways of ensuring regular follow-ups and making educational sessions more interactive and useful to patients.

Supporting quality care for ESRD patients: the social worker can help address barriers to advance care planning

BackgroundAdvance Care Planning (ACP) is essential for preparation for end-of-life. It is a means through which patients clarify their treatment wishes. ACP is a patient-centered, dynamic process involving patients, their families, and caregivers. It is designed to 1) clarify goals of care, 2) increase patient agency over their care and treatments, and 3) help prepare for death. ACP is an active process; the end-stage renal disease (ESRD) illness trajectory creates health circumstances that necessitate that caregivers assess and nurture patient readiness for ACP discussions. Effective ACP enhances patient engagement and quality of life resulting in better quality of care.Main bodyDespite these benefits, ACP is not consistently completed. Clinical, technical, and social barriers result in key challenges to quality care. First, ACP requires caregivers to have end-of-life conversations that they lack the training to perform and often find difficult. Second, electronic health record (EHR) tools do not enable the efficient exchange of requisite psychosocial information such as treatment burden, patient preferences, health beliefs, priorities, and understanding of prognosis. This results in a lack of information available to enable patients and their families to understand the impact of illness and treatment options. Third, culture plays a vital role in end-of-life conversations. Social barriers include circumstances when a patient’s cultural beliefs or value system conflicts with the caregiver’s beliefs. Caregivers describe this disconnect as a key barrier to ACP. Consistent ACP is integral to quality patient-centered care and social workers’ training and clinical roles uniquely position them to support ACP.ConclusionIn this debate, we detail the known barriers to completing ACP for ESRD patients, and we describe its benefits. We detail how social workers, in particular, can support health outcomes by promoting the health information exchange that occurs during these sensitive conversations with patients, their family, and care team members. We aim to inform clinical social workers of this opportunity to enhance quality care by engaging in ACP. We describe research to help further elucidate barriers, and how researchers and caregivers can design and deliver interventions that support ACP to address this persistent challenge to quality end-of-life care.

Patient Engagement and Patient Safety: Are We Missing the Patient in the Center?

The global healthcare delivery paradigm shift calls for enhanced strategies to engage patients in delivering safer and high-quality healthcare. There still exists a gap area in a globally accepted measure for the person-centered care. Recent tri-institutional global quality reports from National Academies of Sciences, Engineering, and Medicine (NAESM), World Bank Group, and Lancet Global Health Commission attempted to report the patient engagement measures used globally. We aim to understand the variation in these globally reported patient-centered care measures and highlight the recent proactive strategies to enhance patient engagement to improve patient safety.I

Challenges in mobile health app research: Strategies for interprofessional researchers

Abstract Aim The purpose of this brief methodological paper is to discuss critical design features and user characteristics that should be considered when scientists from varied health related fields are testing mobile health apps in different patient populations. Background With the growing number of patients using mobile health tracking apps to manage their health and chronic conditions, interprofessional research on these apps is emerging, potentially having a tremendous impact on clinical practice. However, methodological challenges exist when conducting this type of research. Methods Select methodological challenges are illustrated by study examples and supported by various theoretical frameworks. Strategies addressing these challenges are offered to interprofessional researchers who are initiating clinical research in this field of study. Directions for future research are also proposed. Results Customizability, interactivity, usability, and changing health needs are discussed as key design challenges. Age and health literacy are discussed as important user characteristics influencing the adoption of a new technology. Conclusion Mobile health tracking innovations have the potential to benefit patients. Interprofessional teams studying mobile health apps need to understand how apps should be designed for various patient populations, age groups, and literacy abilities to enhance patient engagement with the technology and ultimately support patients’ health needs.

Update on the NAEPPCC Asthma Guidelines: The wait is over, or is it?

As an asthma specialist, one is often asked to discuss the asthma guidelines. The challenge that one faces is deciding which guidelines to use as a resource for discussion or presentation. It often comes down to the following questions: What is the question? What message does one want to deliver? Where is the most current information? and Who is the target audience? This commentary will help answer those questions as it guides the reader through the new update of the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program guidelines and then outlines differences between 2 widely used strategies for the management of asthma: the Global Initiative for Asthma and the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma.

Advancing the learning health system by incorporating social determinants.

The learning health system (LHS) has gained traction as a powerful framework for improving the cost and quality of healthcare. The goal of an LHS is to systematically integrate internal data and experience with external evidence so patients receive higher-quality, safer, and more efficient care. However, if the goal of an LHS is to improve health, as well as healthcare, it must account for and mitigate the negative impact of social and economic factors on health, known as the social determinants of health. In this paper, we discuss the critical role the LHS can play in addressing patients' social risk factors. We also discuss how integrating data on the social determinants and activities to reduce patients' social risk factors could advance the mission of the LHS to enhance patient engagement, improve the delivery of personalized care, and more accurately evaluate the effectiveness of care. Without the collection and integration of data on the social determinants of health, the LHS may fail to reach its full potential to improve health and healthcare.

Interventions to Enhance Patient and Family Engagement Among Adults With Multiple Chronic Conditions: A Systematic Scoping Review.

In the United States, 42% of adults, and 81% of adults over 65 years of age live with multiple chronic condition (MCC). Current interventions to facilitate engagement in care focus primarily on the patient; however, many individuals with MCC manage and live with their conditions within the context of their family. This review sought to identify interventions used to facilitate patient and/or family engagement among adults with MCC. We adhered as closely as possible to PRISMA guidelines and conducted a systematic scoping review using a modified approach by Arksey and O'Malley. We searched PubMed, Web of Science, and Scopus using terms related to MCC, patient and family engagement, and intervention. We included articles that: (1) were published in English; (2) were peer-reviewed; (3) described an engagement intervention (with or without a comparator); and (4) targeted individuals with MCC. We abstracted data from included articles and classified them using the Multidimensional Framework for Patient and Family Engagement in Health and Health Care, and the Classification Model of Patient Engagement. We identified 21 discrete interventions. Six (29%) were classified as having the highest degree of engagement. Eighteen (85%) focused on engagement at the direct care level. Only one was specifically designed to engage families. Many engagement interventions currently exist for adults with MCC. Few of these interventions foster the highest degree of engagement; most focus on engagement at the level of direct care and do not specifically target family member involvement.

Training Patient Stakeholders Builds Community Capacity, Enhances Patient Engagement in Research

Our philosophical framework for research with low-income Latino patients with diabetes prioritizes hiring research staff who share the culture and language of the population of study. Inclusive research design requires an active role by patient stakeholders with training opportunities in a collaborative learning environment to allow patient stakeholder data collectors (PSDCs) to build on existing strengths and expertise. To develop this manuscript, our team reflected on our collective experiences in implementing research-specific trainings for PSDCs. Although our population of study is known to be difficult to recruit and retain, our PSDCs have successfully enrolled participants on schedule, and attrition is low. Although language, institutional requirements, and funding restrictions presented training challenges, we overcame these by using a flexible approach and by incorporating the data collectors' expertise in refining our protocols. We propose that our success in recruiting and retaining participants is a reflection of our engaged research strategy and framework and demonstrates that engagement promotes better science. However, our experience also demonstrates research institutions need to make policy and infrastructural improvements to reduce barriers and make engaged approaches more feasible.

Implementation and Long-Term Outcomes of Organisational Health Literacy Interventions in Ireland and The Netherlands: A Longitudinal Mixed-Methods Study.

Organisational Health Literacy (OHL)-interventions are needed to overcome health inequality. OHL-interventions have successfully identified communication barriers at the organisational level, but evidence is limited on the extent to which this leads to sustainable organisational change. This study aims to assess the implementation fidelity, moderators (barriers and facilitators), and long-term impact of OHL-interventions in hospitals in Ireland and The Netherlands. We used a longitudinal mixed-methods approach to assess two similar OHL-interventions in one Irish and three Dutch hospitals. The OHL-interventions concerned the improvement of navigation and implementation of health literacy-friendly communication throughout organisations. Participants were 24 hospital employees and 40 older adults who use hospital services. At six, eight, and eighteen months, we assessed the level of implementation, barriers and facilitators, and impact through questionnaires and in-depth semi-structured interviews. After older adults and professionals had identified a number of communication problems, we found that professionals had successfully implemented OHL-interventions to promote navigation and comprehensible communication. Limited resources and variation in organisational structures and procedures were perceived as barriers to implementation. The participation of service users, leadership support, and a stepwise implementation of interventions were perceived to facilitate implementation. In the long term, the OHL-interventions led to system-wide improvements, as shown by better embedding of health literacy policies, enhanced patient engagement, provision of plain language training and comprehensible information. Findings were similar for the two countries. Embedded OHL-interventions resulted in sustainable and system-wide health literacy changes in all four hospitals. Following implementation, OHL-interventions have the potential to promote health equity and empowerment among health service users.

Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence.

BackgroundChronic edema (CO) is a progressive, physically disfiguring and currently incurable condition. A multifaceted program has been recommended to manage the swelling. However, there is little evidence investigating patients’ perspectives following the program, particularly for those who have poor adherence and/or are disengaged.AimTo investigate the perceived challenges faced by disengaged participants with lower limb CO by identifying their enablers and barriers to participating in a Physiotherapy CO program.MethodAn exploratory qualitative approach was used. A purposive sampling strategy was adopted to recruit participants. Those with more than three months swelling and who had low adherence and/or attendance (disengaged) to the CO program were invited to participate. Semi-structured interviews with six participants from a CO clinic in a tertiary hospital were conducted. Data were thematically analyzed and findings in terms of enablers and barriers were subsequently reflected in the light of a theoretical framework.ResultsAll six participants were morbidly obese (BMI 47 ± 4 kg/m2) with multiple chronic comorbidities. Enablers and barriers detected included physical, psychological and social factors that interplay to present multidimensional challenges that influence the participants’ adjustment to managing their CO. For the disengaged participants in this study, their under-managed lower limb CO was a progression towards being housebound and having a gradually increasing level of disability.ConclusionThis study has identified the multidimensional challenges faced by low adherent and/or disengaged participants with lower limb CO to participating in a hospital-based CO program. Perceived enablers and barriers included physical, psychological and social factors. These were mapped using a health behavior change theoretical framework. Understanding these challenges has implications for developing a multidisciplinary approach aimed at enhancing patient engagement and participation in the physiotherapy CO program.

Religiosity and Patient Activation Among Hospital Survivors of an Acute Coronary Syndrome.

Optimum management after an acute coronary syndrome (ACS) requires considerable patient engagement/activation. Religious practices permeate people's lives and may influence engagement in their healthcare. Little is known about the relationship between religiosity and patient activation. To examine the association between religiosity and patient activation in hospital survivors of an ACS. Secondary analysis using baseline data from Transitions, Risks, and Actions in Coronary Events: Center for Outcomes Research and Education (TRACE-CORE) Study. A total of 2067 patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). Study participants self-reported three items assessing religiosity-strength and comfort from religion, making petition prayers, and awareness of intercessory prayers for health. Patient activation was assessed using the 6-item Patient Activation Measure (PAM-6). Participants were categorized as either having low (levels 1 and 2) or high (levels 3 and 4) activation. The mean age of study participants was 61years, 33% were women, and 81% were non-Hispanic White. Approximately 85% derived strength and comfort from religion, 61% prayed for their health, and 89% received intercessory prayers for their health. Overall, 58% had low activation. Reports of a great deal (aOR, 2.02; 95% CI, 1.44-2.84), and little/some (aOR, 1.45; 95% CI, 1.07-1.98) strength and comfort from religion were associated with high activation, as were receipt of intercessions (aOR, 1.48; 95% CI, 1.07-2.05). Praying for one's health was associated with low activation (aOR, 0.78; 95% CI, 0.61-0.99). Most ACS survivors acknowledge religious practices toward their recovery. Strength and comfort from religion and intercessory prayers for health were associated with high patient activation. Petition prayers for health were associated with low activation. Healthcare providers should use knowledge about patient's religiosity to enhance patient engagement in their care.

Use of an Ambulatory Patient Portal for Advance Care Planning Engagement.

Primary care clinics need sustainable, population-based approaches to engage patients in advance care planning (ACP). Patient portal-based ACP tools may provide an option for patient engagement. To increase ACP outcomes by engaging older adults through portal-based ACP tools, including an electronic Medical Durable Power of Attorney (MDPOA) form. Geriatric clinic pilot of a multi-modal population-based outreach strategy for portal-based ACP tools. Outreach was to patients (n = 105) who were 65 years and older with an active portal account, no cognitive impairment, and no MDPOA on file. Patients received a motivational message via the portal and, if not read within 2 weeks, a mailed postcard about the portal-based ACP tools. Primary outcome was composite of any ACP action at 1-year including 1) new advance directive (AD) in the electronic health record, 2) use of portal-based ACP tools, or 3) documented ACP discussion with a provider. Sixty-five older adults read the electronic message at 12 months. Seventeen (16%) engaged in at least 1 ACP action. Fourteen of 17 engaged by adding an AD to their record. More patients completed an AD on article or brought a previously completed AD to clinic, compared with choosing to complete an electronic MDPOA via the portal. Brief motivational messages about ACP via a patient portal is feasible and may increase ACP outcomes for older adults in primary care. Future studies should evaluate population-based portal outreach strategies in combination with team-based workflows to enhance patient engagement in ACP.

421 Improving Proton Pump Inhibitor Prescribing Practices in an Academic Safety Net Primary Care Clinic: Quality Improvement Project

INTRODUCTION: Proton Pump Inhibitors (PPI) overuse in both inpatient and outpatient settings have increased drastically over the last 2 decades. Overuse of PPIs continues despite evidence based guidelines and prolonged PPI use carries serious adverse effects. The aim of this quality improvement (QI) is to reduce the percentage of patients inappropriately prescribed PPIs between the ages of 40-75 years from a baseline rate of 80% to &lt; 60% within 1 year at ECMC internal medicine clinic (IMC). METHODS: We used the Plan-Do-Study-Act (PDSA) model and performed a root cause analysis to identify barriers for the reduction of inappropriate use of PPIs. The major barriers included system, provider and patient-based barriers including lack of electronic medical record (EMR) alerts, gaps in knowledge in both the provider and the patient, fear of discontinuation of the PPI. QI team included nursing and ancillary staff, residents, attending physicians, social worker. Outcome measure was to reduce the percentage of patients inappropriately prescribed PPIs from 80% to &lt; 60% in 1 year. Process measures included measuring the percentage of patients who are appropriately referred to GI clinic for an EGD and the percentage of patients on PPI who have their GERD assessed during the clinic including assessment for alarm symptoms. Balancing measures included potential increase in patient wait times in the clinic and esophagogastroduodenoscopy (EGD) wait time. The major interventions included (1) creating a customized EMR template; (2) provider education; (3) tracking continuity of care visits and medication reconciliation; (4) patient education; (5) assessing barriers and response to discontinuation; (6) Pocket guides for physician education. RESULTS/OUTCOME MEASURES: Average rates of PPI discontinuation were 51.1% (n = 92/180), resulting into 30.0% inappropriate chronic PPI use from the baseline rates of 80% within 1 year. Process measures: The total percentage of patients on long term PPI use who had an EGD was recorded as 51.1% which improved from the baseline of &lt; 30%. The EGD completion rates in eligible patients was 43.6% from baseline of &lt; 20%. CONCLUSION: We exceeded the goal, achieved &gt;50% reduction in inappropriate use of chronic PPI use within 1 year. Lack of automated medical decision support tool was identified as the biggest barrier. Optimization of EHR and education to QI team members were crucial for the success of this QI. Future directions include enhancing patient engagement and spread to other clinics.

TReatIng Urinary symptoms in Men in Primary Healthcare using non-pharmacological and non-surgical interventions (TRIUMPH) compared with usual care: study protocol for a cluster randomised controlled trial

BackgroundLower urinary tract symptoms (LUTS) can relate to urinary storage or voiding. In men, the prevalence and severity of LUTS increases with age, with a significant impact on quality of life. The majority of men presenting with LUTS are managed by their general practitioner (GP) in the first instance, with conservative therapies recommended as the initial treatment. However, the provision of conservative therapies in primary care is variable and can be time and resource limited. GPs require practical resources to enhance patient engagement with such interventions. TRIUMPH aims to determine whether a standardised and manualised care intervention delivered in primary care achieves superior symptomatic outcome for LUTS versus usual care.Methods/designTRIUMPH is a two-arm, cluster randomised controlled trial (RCT) being conducted in 30 National Health Service (NHS) general practices in England. The TRIUMPH intervention comprises a standardised LUTS advice booklet developed for the trial with patient and healthcare professional (HCP) consultation. The booklet is delivered to patients by nurses/healthcare assistants following assessment of their urinary symptoms. Patients are directed to relevant sections of the booklet, providing the manualised element of the intervention. To encourage adherence, HCPs provide follow-up contacts over 12 weeks. Practices are randomised 1:1 to either deliver the TRIUMPH intervention or a usual care pathway. The patient-reported International Prostate Symptom Score (IPSS) at 12 months post consent is the primary outcome. Secondary outcomes include cost-effectiveness, patient-reported outcomes on LUTS, quality of life, and patient and HCP acceptability and experience of the intervention. Primary analyses will be conducted on an intention-to-treat basis.DiscussionIt is unclear whether conservative therapies for male LUTS are effectively delivered in primary care using current approaches. This can lead to men being inappropriately referred to secondary care or experiencing persistent symptoms. Primary care, therefore, holds the key to effective treatment for these men. The TRIUMPH intervention, through its standardised and manualised approach, has been developed to support GP practices in delivering effective conservative care. This pragmatic, cluster RCT should provide robust evidence in a primary-care setting to inform future guidelines.Trial registrationISCRTN registry, ID: ISRCTN11669964. Registered on 12 April 2018.