Improve Care Delivery Research Articles

CARDIOVASCULAR OUTCOMES OF ACUTE CORONARY SYNDROMES IN INDIGENOUS COMPARED WITH NON-INDIGENOUS PATIENTS IN NORTHERN SASKATCHEWAN

<h3>BACKGROUND</h3> Indigenous compared with non-Indigenous patients have historically been known to have higher cardiovascular risk. With improved care delivery of acute myocardial infarction, we sought to compare contemporary profiles between indigenous versus non-Indigenous patients presenting with acute coronary syndromes (ACS) to a single PCI cardiac center in Saskatchewan. <h3>METHODS AND RESULTS</h3> We prospectively evaluated consecutive ACS admissions (no exclusion criteria applied) from March 15, 2019 to March 30, 2021 at the Royal University Hospital, Saskatoon. Categorized by self-reported Indigenous and non-Indigenous status, we describe presenting demographics, treatment patterns, unadjusted all-cause mortality and all-cause rehospitalization. Continuous variables are presented as medians (25th, 75th percentiles), categorical values as frequencies (%). Of the 1950 ACS admissions, 260 (13.3%) were Indigenous. Indigenous compared with non-Indigenous patients were younger, more likely female, have a history of heart failure and a significant burden of both traditional and non-traditional cardiovascular risk factors. Both groups were revascularized comparably with PCI. Indigenous compared with non-Indigenous patients were however more likely to present with higher levels of NTproBNP and higher incident rates of cardiogenic shock and/or cardiac arrest, with a greater severity of left ventricular systolic dysfunction (Table 1). While in-hospital mortality is comparable between the two groups, Indigenous compared with non-Indigenous have significantly higher unadjusted 1-year mortality (11.9% vs. 8.0%, p=0.039). <h3>CONCLUSION</h3> Indigenous compared with non-Indigenous patients hospitalized with an acute coronary syndrome have a significantly greater burden of premorbid cardiovascular risk and present with greater clinical acuity. While the in-hospital outcomes are comparable, likely due to established pre-hospital/in-hospital ACS processes of care, the higher one-year mortality suggest that the higher residual risk in Indigenous patients is likely driven by the greater burden of modifiable traditional and non-traditional risk factors in this patient population.

Trends in Chronic Kidney Disease Care in the US by Race and Ethnicity, 2012-2019

Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care. To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. The independent variables were race and ethnicity, as reported in linked electronic health records. On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients. Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.

Statistical Process Control Charts for Monitoring Next-Generation Sequencing and Bioinformatics Turnaround in Precision Medicine Initiatives

PurposePrecision oncology, such as next generation sequencing (NGS) molecular analysis and bioinformatics are used to guide targeted therapies. The laboratory turnaround time (TAT) is a key performance indicator of laboratory performance. This study aims to formally apply statistical process control (SPC) methods such as CUSUM and EWMA to a precision medicine programme to analyze the learning curves of NGS and bioinformatics processes.Patients and MethodsTrends in NGS and bioinformatics TAT were analyzed using simple regression models with TAT as the dependent variable and chronologically-ordered case number as the independent variable. The M-estimator “robust” regression and negative binomial regression were chosen to serve as sensitivity analyses to each other. Next, two popular statistical process control (SPC) approaches which are CUSUM and EWMA were utilized and the CUSUM log-likelihood ratio (LLR) charts were also generated. All statistical analyses were done in Stata version 16.0 (StataCorp), and nominal P < 0.05 was considered to be statistically significant.ResultsA total of 365 patients underwent successful molecular profiling. Both the robust linear model and negative binomial model showed statistically significant reductions in TAT with accumulating experience. The EWMA and CUSUM charts of overall TAT largely corresponded except that the EWMA chart consistently decreased while the CUSUM analyses indicated improvement only after a nadir at the 82nd case. CUSUM analysis found that the bioinformatics team took a lower number of cases (54 cases) to overcome the learning curve compared to the NGS team (85 cases).ConclusionAs NGS and bioinformatics lead precision oncology into the forefront of cancer management, characterizing the TAT of NGS and bioinformatics processes improves the timeliness of data output by potentially spotlighting problems early for rectification, thereby improving care delivery.

A nurse practitioner-led care bundle approach for primary care of patients with complex health needs.

Often developed for acute care and less frequently for primary care, care bundles are clusters of evidence-based practices for improving care delivery and patient outcomes. Care bundles usually arise when ineffective or costly outcomes are identified, are meant to make care more reliable, and require superb teamwork and communication. Patients using the highest proportion of health care services are those living with complex health conditions and challenging sociocultural lives, statistics corroborated within our primary care clinic. In our nurse practitioner (NP)-led, interprofessional, team-based primary care program serving mainly low-income patients, we noted that many patients with multiple chronic conditions had an excess of clinic encounters, emergency department visits, and hospitalizations. To improve health status for these patients and reduce costly care inefficiencies, we developed a unique bundle of care practices for embedding within our NP-led complex care program. Our goals were to improve patient efficacy for self-management of chronic conditions and promote appropriate use of health care resources and services. Using AEIØOU as a mnemonic, the derived care bundle better focused our team efforts and provided us with a planning, communication, and documentation schema for quality improvement. It was particularly useful for team-based care because tasks could be documented or communicated by letter or number and easily reviewed by team members or others involved in patients' care. Use of the AEIØOU bundle within our program resulted in better coordination of team-based comprehensive care for our high-needs patients, seen anecdotally in fewer unnecessary contacts and missed appointments and in patient appreciation comments. Emergency department visits and hospitalization data for the six months before compared with 6 months after enrollment in the program showed significant reductions. To improve the primary care of complex patient populations, we recommend further use and testing of the AEIØOU bundle within other care models.

Applying User-Centered Design to Develop Practical Strategies that Address Overuse in Primary Care.

Engaging patients and frontline clinicians in re-designing clinical care is essential for improving care delivery in a complex clinical environment. This study sought to assess an innovative user-centered design approach to improving clinical care quality, focusing on the use cases of de-intensifying non-beneficial care within the following areas: (1) de-intensifying diabetes treatment in high-risk patients; (2) stopping screening for carotid artery stenosis in asymptomatic patients; and (3) stopping colorectal cancer screening in average-risk, older adults. The user-centered design approach, consisting of patient and patient-clinician charrettes (defined as intensive workshops where key stakeholders collaborate to develop creative solutions to a specific problem) and participant surveys, has been described previously. Following the charrettes, we used inductive coding to identify and categorize themes emerging from the de-intensification ideas prioritized by participants as well as facilitator notes and audio recordings from the charrettes. Thirty-five patients participated in the patient design charrettes, generating 134 unique de-intensification ideas and prioritizing 32, which were then distilled into six patient-generated principles of de-intensification by the study team. These principles provided a starting point for a subsequent patient-clinician charrette. In this follow-up charrette, 9 patients who had participated in an earlier patient design charrette collaborated with 7 clinicians to generate 63 potential de-intensification solutions. Six of these potential solutions were developed into multi-faceted, fully operationalized de-intensification strategies. The de-intensification strategies that patients and clinicians prioritized and operationalized during the co-design charrette process were detailed and multi-faceted. Each component of a strategy had a rationale based on feasibility, practical considerations, and ways of overcoming barriers. The charrette-based process may be a useful way to engage clinicians and patients in developing the complex and multi-faceted strategies needed to improve care delivery.

Practical Measures for Dealing With the Struggles of Nurses Caring for People With Amyotrophic Lateral Sclerosis Comorbid With Cognitive Impairment in Japan

Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disease for which there is currently no cure. This study aimed to explore the situations with which nurses struggled, their implemented practical measures, and the challenges they experienced when caring for patients with ALS comorbid with cognitive impairment (hereinafter, targeted patients). In this qualitative study, we conducted a survey with nurses (n = 121) experienced in caring for ALS patients; the survey contained a free-writing section in which participants described their struggles regarding care delivery for these patients. To collect data on practical measures that nurses had already implemented or wanted to propose regarding care delivery for the targeted patients, we conducted four focus group interviews (n = 22). We used a qualitative inductive approach to extract the categories. Fifty-eight nurses (49.6%) completed the free-writing survey section. The situations in which nurses struggled in care for the targeted patients were organized into three categories: “Patients’ strong persistency on specific requirements for nursing assistance in their daily lives,” “Patients’ problematic behaviors toward nurses,” and “Struggles in communicating with and understanding patients’ wishes.” Nurses reported these situations as stressful, and they affected care quality. The practical measures implemented when caring for the targeted patients were organized into five categories: “Cognitive impairment assessment,” “Care delivery to deal with patients’ strong persistency on specific requirements for assistance in their daily lives,” “Communication,” “Supporting the decision-making process,” and “Collaboration between the hospital and the community.” Multidisciplinary collaboration in the hospital, and collaboration between the hospital and the community from an early stage is necessary to share the results of the assessment and diagnosis of cognitive impairment. Our evidence underlines that guideline and care manual establishment may lead to improved care delivery and to the unification of care deliveries to respond to patients’ strong persistency.

Journey mapping as a novel approach to healthcare: a qualitative mixed methods study in palliative care

BackgroundJourney mapping involves the creation of visual narrative timelines depicting the multidimensional relationship between a consumer and a service. The use of journey maps in medical research is a novel and innovative approach to understanding patient healthcare encounters.ObjectivesTo determine possible applications of journey mapping in medical research and the clinical setting. Specialist palliative care services were selected as the model to evaluate this paradigm, as there are numerous evidence gaps and inconsistencies in the delivery of care that may be addressed using this tool.MethodsA purposive convenience sample of specialist palliative care providers from the Supportive and Palliative Care unit of a major Australian tertiary health service were invited to evaluate journey maps illustrating the final year of life of inpatient palliative care patients. Sixteen maps were purposively selected from a sample of 104 consecutive patients. This study utilised a qualitative mixed-methods approach, incorporating a modified Delphi technique and thematic analysis in an online questionnaire.ResultsOur thematic and Delphi analyses were congruent, with consensus findings consistent with emerging themes. Journey maps provided a holistic patient-centred perspective of care that characterised healthcare interactions within a longitudinal trajectory. Through these journey maps, participants were able to identify barriers to effective palliative care and opportunities to improve care delivery by observing patterns of patient function and healthcare encounters over multiple settings.ConclusionsThis unique qualitative study noted many promising applications of the journey mapping suitable for extrapolation outside of the palliative care setting as a review and audit tool, or a mechanism for providing proactive patient-centred care. This is particularly significant as machine learning and big data is increasingly applied to healthcare.

A Master Class in Family Doctor Leadership: Evaluating an Innovative Program.

In family medicine, leadership is critical for health care delivery, advancing curricula, research, and quality improvement. Systematic reviews of leadership development programs in health care identify limitations, calling for innovative designs and rigorous assessment. Our objective was to evaluate the impact of applying master class principles to leadership development in academic family medicine. We used mixed methods to assess the impact of an innovative master class program on 15 emerging leaders in a large academic department of family medicine. The program consisted of five sessions where family physician masters shared their wisdom, techniques, and feedback with promising leaders. Quantitative evaluation involved participants' ratings of each session's content and delivery using a 5-point Likert scale. We assessed postcourse semistructured interviews with participants qualitatively using descriptive thematic content analysis. Individual sessions were highly evaluated, with a combined mean of 4.82/5. Qualitative thematic analysis identified self-perceived increased effectiveness in leadership activities; increased confidence as a leader; increased motivation to be a leader; and perceptions of value from the program, contributing to what participants described as unexpected potential change within themselves. Themes related to effectiveness of the program were practical advice; networking; diverse topics; accessible speakers sharing personal stories; and small-group, informal, early-evening format. Master class concepts can be adapted to leadership development in academic family medicine, with evidence of early positive impact on participants' self-perception of leadership skills and confidence. Further research is warranted to assess organizational impact and applicability to other settings.

Three Learning Organizations in Cataract Surgery: The Example of Intracameral Antibiotic Injection.

The recent systematic adoption of intracameral antibiotic injection during cataract surgery in Sweden, India, and the US serves as a model for the successful transitioning of local quality improvement initiatives to organization-wide implementation. Although the delivery of eye care in the 3 countries is distinctly organized with differing governances and technological infrastructure, each contains elements of a learning organization (ie, an organization that has adopted a culture of creating, acquiring, and transferring knowledge into practice through system-level and clinician-level change). We describe a retrospective and organizational implementation study of intracameral antibiotic injection in Sweden, through the efforts of the National Cataract Registry; in the US by Kaiser Permanente; and in India by the Aravind Eye Hospital System. Leadership structure, training in problem solving, benchmarking, sharing of technical knowledge, and data and workforce engagement are compared. Each of the 3 organizations share the key elements of effective leadership, which values the exchange of ideas in the workforce, training and resourcing for change, and information management in the form of benchmarking and data sharing. In the case of intracameral antibiotic injection, a new technique was identified to improve quality and safety with a reduction in infections as evidence of the success of the programs. Committing to a culture of collective learning, and leveraging each stakeholder's personal investment, health-care systems may improve care delivery and set new benchmarks in quality and safety.

Improving Care Delivery: Location Timestamps to Enhance Process Measurement of a Clinical Workflow.

We applied the FOCUS-Plan-Do-Check-Act framework to reduce the time from arrival to sedation for long-bone fractures. First, we added supplementary framework-defining steps to repeat the Clarifying and Understanding steps. We then extracted objective time-based data from an electronic health record (EHR) system and a real-time locating system (RTLS). We then compared and contrasted the findings of traditional surveys with analyses of timed steps within the sedation workflow. When identifying the source of delays, traditional survey techniques yielded ambiguous and even conflicting results based on clinical roles. The timestamps supported 5 measurable clinical role of subworkflows. By measuring the time to completion for 54 sedation cases, workflow patterns and significant bottlenecks were identified. Analyzing the time to complete individual tasks provided a more nuanced description of workflow delays and clarity when traditional survey results conflicted. Augmenting traditional QI process maps with EHR and RTLS timestamps better explained workflow bottlenecks, informing the QI team when selecting targets for subsequent Plan-Do-Check-Act work.

Schooling and Nigerian Children with Asthma: A Review of Challenges, Risk and Prospects.

Epidemiologic studies have reported increasing prevalence of childhood asthma in Nigeria and other developing countries where there are parallel increases in school enrolments. Children with asthma face lots of challenges in school which can affect their academic performance and quality of life. This narrative review highlights the challenges and the risks of schooling encountered by Nigerian children with asthma and the prospects of utilizing the School Health Programme (SHP) to overcome these challenges. An electronic search of relevant published articles from 2000 to 2020 was carried out using appropriate search engines for the following words: "schooling", "childhood asthma", "school health programme", "school environment," "health instructions", "school health services" and "asthma care in schools". The challenges and risks the school age asthmatics encounter in school include discrimination and victimization, exposure to triggers on the road and in the school environment, poor and non-existence asthma care services in schools, suboptimal knowledge of teachers and caregivers about childhood asthma hence poor asthma-related instructions and increased school absenteeism. The prospects of SHP as a tool to overcome these challenges are highlighted. These include the roles expected to be played by all stakeholders - the government and education authorities need to revise and more effectively implement the school health policy. The roles of asthma care professionals include the need to "adopt" schools to ensure optimal asthma care for the school population and the all-important enlightenment of teachers, school health workers, parents/caregivers and school children for overall improved asthma care delivery in Nigerian schools.

Impact of guideline-recommended dietitian assessments on weight gain in infants with cystic fibrosis

Cystic fibrosis (CF)-specialized nutrition care strives to meet normal infant growth, but the relationship of dietitian assessments to weight outcomes is unknown. We characterize nutrition management for inadequate weight gain and assess association of dietitian assessments and center-level weight-for-age Z-scores (WAZ). We used encounter data from 226 infants across 28 US CF Centers from the Baby Observational Nutritional study between January 2012 through December 2017. We identified dietitian assessments and consensus guideline-recommended responses to inadequate weight gain: calorie increases, pancreatic enzyme replacement therapy (PERT) increases, or shortened time to next visit. We compared center assessments by funnel plot and summarize median WAZ by center. Of 2,527 visits, 808 (32%) visits had identified inadequate weight gain, distributed in 216 infants. Assessments occurred in 1953 visits (77%), but varied widely between centers (range 17% - 98%). For inadequate weight gain, most and least common responses were calorie increase (64%) and PERT increase (21%). Funnel plot analysis identified 4 high-performers for frequent dietitian assessments (range 92% - 98%) and 4 under-performers (range 17% - 56%). High-performers treated inadequate weight gain more often with adequate calories (24/30, 80% v. 12/23, 52%) and closer follow up (104/164, 63% v. 60/120, 49%) compared to under-performers. Three of 4 high-performing sites met center nutrition goals for positive median WAZ at 2 years old unlike 3 under-performers (WAZHigh 0.33 v. WAZLow -0.15), despite similar patient characteristics. We characterized multicenter variation in dietitian assessments, identifying opportunities to improve care delivery to target early nutrition outcomes.

The Lived Experience of Nurses Caring for Patients Diagnosed With Intravenous Drug Use-Associated Infective Endocarditis in Appalachia: A Phenomenological Study.

The number of patients admitted with infective endocarditis (IE) from intravenous drug use (IVDU) in Appalachia is increasing, a direct downstream effect of the opioid crisis. Extant literature highlights the pejorative attitudes health care workers have toward patients with substance use disorder, with nurses among the most punitive. Rather than describe attitudes, the purpose of this study was to describe the lived experiences of nurses caring for patients diagnosed with IE from IVDU in Appalachia. To describe an unexplored phenomenon in Appalachia to inform nursing practice, nursing education, and health policy. Qualitative phenomenological study using the University of Tennessee method based on the tenets of Maurice Merleau-Ponty. Nine nurses (ages 29-53 years) recruited using purposive and snowball sampling participated in unstructured phenomenological interviews. The essential meaning or central theme of the nurse experience working with these patients was a sense of hopelessness/hope, with four interrelated themes derived from the central theme: (1) guarding/escaping, (2) responsibility and revulsion, (3) apathy/empathy, and (4) grief and sorrow/cold and unemotional. Universally, nurses perceived caring for this population as futile, feeling a sense of powerlessness to change the outcome. These care experiences frustrated nurses, who described being physically and emotionally drained. To improve care delivery and improve patient outcomes, emphasis must be placed on nurse addiction education and standardizing nurse to patient with substance use disorder ratios to decrease work-related stress on nurses.

A Narrative Review of Trauma Care Delivery in India: Challenges and Opportunities

It is estimated that the cost of road accidents in India is around 3% of the Gross Domestic Product of the country. On average, 400 persons die daily in road accidents in India, and cities, such as New Delhi and the national capital region are on the top of the list of road accident causalities. Based on the Basilica agreement, the Indian government has initiated various policy changes and infrastructure development along the national highways which include the redesign of blindspots on the roads and the infliction of heavy penalties for the violation of traffic rules and compliances. On the academic front, the Indo-US Emergency Medicine forum has inaugurated an academic college for emergency medicine in India that cooperates with various government and private healthcare providers and policymakers for the improvement of emergency/trauma care delivery. Lately, few business schools and healthcare educational institutes have focused on interdisciplinary training and research centers in the area of emergency care delivery. Policymakers are also proactively working with various organizations to implement new rules and compliance mechanisms. This prospective study entails a detailed review of the literature using keywords in the PubMed journals, news articles, and media reports. Authors encountered studies in the area of trauma care delivery in India and other countries in their comprehensive field research. Almost 100% of the cases were medico-legal and only one case out of 100 was an insured patient. Furthermore, 87% of the cases were new and only 13% were review cases. Based on the conducted analysis, the number of accidents reduced across the country after the implementation of the New Motor Vehicle Act in the year 2019. It is worth mentioning that, the government launched awareness programs for the public as well. Some of the major challenges identified included lack of coordination and institutional mechanisms for an integrated emergency care delivery, poor referral processes, inadequate ambulance services, lack of third-party coordination, and poor in-hospital resources, particularly in public healthcare organizations. Apart from these, there was an acute shortage of trained emergency medicine experts at all levels. Trauma care delivery is a complex issue and its accomplishment requires good coordination and collaboration among stakeholders. The study identified various challenges and opportunities for the improvement of trauma care delivery in India. There is an immense need and opportunity for the modification of the emergency care delivery system through the introduction of appropriate changes in the transportation policy, emergency care delivery models, institutional mechanisms, such as referral process, and appropriate resource allocation at different levels of care delivery system.

Understanding the barriers to quality care in ovarian cancer: results from a needs assessment and quality improvement initiative

Objectives: The Association of Community Cancer Centers (ACCC) launched an initiative to improve care for patients with ovarian cancer (OVCA) in the United States. The project was designed to identify areas of greatest need for quality improvement (QI) initiatives aimed at improving OVCA care. Methods: A needs assessment survey and workshop application was designed by a multidisciplinary committee and was administered online using Qualtrics. A full day onsite workshop was conducted with the care teams at each site which included a lecture by an OVCA expert, a guided discussion to identify problems and barriers to optimal care delivery, and development of a problem statement for the resulting project. A 6-month QI project utilizing Plan-Do-Study-Act Cycles was developed by each site with data benchmarks. Project specific data was collected and analyzed. Results: 26 programs submitted workshop applications. Program types varied, with the majority being Comprehensive Community Cancer Programs (n=6, 26.1%); Academic Comprehensive Cancer Programs (n=5, 21.7%); or NCI-Designated Comprehensive Cancer Programs (n=5, 21.7%). The median number of annual OVCA patients diagnosed per site was 50.5 (range 22-190). The median numbers of clinical trials per site were 0 Phase I, 1.5 Phase II, and 2 Phase III. Eighty-five percent of sites reported having OVCA multidisciplinary care teams. Genetic testing and counseling (GTC) was the most frequently requested topic for QI (see Table). Three sites were chosen for QI projects. Site 1 chose to improve GTC rates for patients with newly diagnosed OVCA by implementing an electronic medical record (EMR) notification. During the 6-month project, receipt of any genetic testing within 60 days of an initial encounter improved from 68% to 77% of patients. Site 2 also chose to improve the receipt and efficiency of GTC through the development and application of an EMR smartset. During the QI period, GTC improved from 4/27 (15%) retrospectively to 14/14 (100%) with time from diagnosis to GTC decreasing from 1-8 months to 0.5-2 months. The QI project at Site 3 was to improve enrollment onto clinical trials though insertion of an EMR phrase in the template relating to clinical trial eligibility. No change in clinical trials enrollment was identified during the QI period which spanned the initial phase of the COVID-19 pandemic. Download : Download high-res image (146KB) Download : Download full-size image Conclusions: Significant needs for the improvement of quality care delivery for patients with OVCA were identified across varied cancer care programs. Improved access to genetic testing and counseling was the most commonly identified need, followed by enhanced clinical trial enrollment. Using EMR tools, sites were able to rapidly increase rates of GTC. Increasing clinical trial enrollment using an EMR trigger was unsuccessful, largely due to effects of the COVID-19 pandemic. Ongoing work to improve the implementation of best practices in OVCA treatment is needed.

Clinic screening for adverse childhood experiences in people living with HIV to Improve Care Delivery

ABSTRACT Adverse childhood experiences (ACEs) are associated with negative health outcomes; however, screening for ACEs is not routinely performed among people living with HIV (PLWH). We conducted a single-center, cross-sectional pilot study to define the (1) prevalence of ACEs in PLWH and (2) acceptability of ACEs screening in routine out-patient clinical care. One hundred participants completed screening: median age of participants was 49 years (interquartile range: 38.5-59.5), 73% male, 66% Non-Hispanic Black/African American, and 47% gay/lesbian. Clinically significant ACEs score, defined as ≥4, was reported in 51%. High ACEs score was more common among participants <50 years old (64.7% vs. 36.7%; p < 0.01), but the prevalence of ACEs ≥4 did not differ by gender, race, ethnicity, or sexual orientation. Among participants with ≥4 ACEs, 44.4% screened negative on both PHQ-9 and PC-PTSD screens. The majority of participants (89%) reported a positive experience with ACEs screening. The prevalence of clinically significant ACEs in this clinic population of PLWH was more than twice that reported in the general population. Routine ACEs screening can improve delivery of trauma-informed care in the HIV primary care setting.

Rural Disparities in Lung Cancer-directed Surgery: A Medicare Cohort Study.

The primary objective of this study was to determine the influence of rural residence on access to and outcomes of lung cancer-directed surgery for Medicare beneficiaries. Lung cancer is the leading cause of cancerrelated death in the United States and rural patients have 20% higher mortality. Drivers of rural disparities along the continuum of lung cancercare delivery are poorly understood. Medicare claims (2015-2018) were used to identify 126,352 older adults with an incident diagnosis of nonmetastatic lung cancer. Rural Urban Commuting Area codes were used to define metropolitan, micropolitan, small town, and rural site of residence. Multivariable logistic regression models evaluated influence of place of residence on 1) receipt of cancer-directed surgery, 2) time from diagnosis to surgery, and 3) postoperative outcomes. Metropolitan beneficiaries had higher rate of cancer-directed surgery (22.1%) than micropolitan (18.7%), small town (17.5%), and isolated rural (17.8%) (P < 0.001). Compared to patients from metropolitan areas, there were longer times from diagnosis to surgery for patients living in micropolitan, small, and rural communities. Multivariable models found nonmetropolitan residence to be associated with lower odds of receiving cancer-directed surgery and MIS. Nonmetropolitan residence was associated with higher odds of having postoperative emergency department visits. Residence in nonmetropolitan areas is associated with lower probability of cancer-directed surgery, increased time to surgery, decreased use of MIS, and increased postoperative ED visits. Attention to timely access to surgery and coordination of postoperative care for nonmetropolitan patients could improve care delivery.

Life Interrupted: Experiences of adolescents, young adults and their family living with malignant melanoma.

Melanoma is one of the most common human malignancies; yet, it is often thought of as a disease of adulthood rather than one affecting adolescents and young adults. This study sought to understand the experiences of adolescents, young adults and their family living with malignant melanoma. A qualitative study using Interpretive Phenomenological Analysis, through a multi-perspective design. Data collection was conducted between January and August 2018 in each participant's Primary Care Centre when they were attending for an outpatient appointment. Each young person and a nominated family member were interviewed (n=10) either individually (n=4) or as a dyad (n=6) according to their personal choice. In-depth semi-structured interviews were conducted and audio-recorded with the participant's consent. Interview data were transcribed verbatim and analysed. The metanarrative 'Life Interrupted' was the core conceptual thread woven throughout the findings. It represents the interconnections and interrelationships between the adolescent or young adult and their family. Being able to recognize the disease and seek support was challenging with often limited physical, emotional or social support resulting in feelings of fear and isolation. Four super-ordinate themes were identified: (a) 'Is it Serious', (b) 'Too Much too Young', (c) 'Not the Same' and (d) 'Time to Live'. With the rising incidence of MM in the adolescents and young adults population globally, there are demands to improve healthcare professionals and nurse's knowledge and understanding of MM. As young people with MM experience their journey outside specialist cancer services, the care delivery for this patient group and their families require stronger links between services. This study will inform the improvement of care delivery for MM in order that this patient group is provided with the same access to service delivery as other adolescents and young adults with cancer.

T1D Exchange Quality Improvement Collaborative: A Learning Health System to Improve Outcomes for All People With Type 1 Diabetes.

Medical advances, including the development of new medications and advanced technologies, have the potential to improve outcomes for youths and adults with type 1 diabetes, but that potential has not yet been fully realized, particularly in minority groups and those with low socioeconomic status (SES). The report by Majidi et al. in this issue (1) adds to the growing literature exposing racial and ethnic inequities in type 1 diabetes. These data, derived from a mostly young cohort (76% <26 years of age), show that non-Hispanic Blacks experienced higher rates of diabetic ketoacidosis (DKA), higher A1C levels, and lower use of technology compared with non-Hispanic Whites. Non-Hispanic Black patients with type 1 diabetes who are hospitalized with coronavirus disease 2019 are also more likely to present in DKA (2). There is a crucial need to address barriers to care and provide resources to overcome unjust and avoidable health disparities that persist within nondominant racial and ethnic groups (3). Understanding and addressing these barriers can be achieved by understanding our current state and implementing interventions to decrease barriers and improve outcomes. In 2016, the T1D Exchange established the T1D Exchange Quality Improvement Collaborative (T1DX-QI). This collaborative started with 10 pilot sites, which were primarily well-respected, academic pediatric diabetes centers. Its initial focus was on children and adolescents/emerging adults with type 1 diabetes, the group who has the highest A1C levels (4,5). Since then, the T1DX-QI has continued to expand, now encompassing 30 centers across the United States (Figure 1), and is beginning to direct attention to adults as well as youths with type 1 diabetes. Participating centers strive to improve care delivery and health outcomes and reduce barriers to care for everyone with type 1 diabetes by sharing best practices and data benchmarking (6). FIGURE 1 Geographical distribution of T1DX-QI sites. …

Quality Improvement in Diabetes Care: A Review of Initiatives and Outcomes in the T1D Exchange Quality Improvement Collaborative.

Despite immense strides in therapeutic advances, clinical outcomes continue to be less than ideal for people with type 1 diabetes. This discrepancy has prompted an outpouring of quality improvement (QI) initiatives to address the medical, psychosocial, and health equity challenges that complicate ideal type 1 diabetes care and outcomes. This article reviews a framework for QI in diabetes care that guided the development of the T1D Exchange Quality Improvement Collaborative to improve care delivery and health outcomes in type 1 diabetes. Evaluation of the methodology, outcomes, and knowledge gained from these initiatives will highlight the importance of continued QI initiatives in diabetes care.