Optimal Health Care Delivery Research Articles

Dissemination and Implementation Research: Intersection between Nursing Science and Health Care Delivery

Dissemination is the targeted distribution of information and intervention materials to spread knowledge and evidence-based interventions to a larger audience (NIH, 2011). Implementation is the use of strategies to promote the systematic uptake of evidence-based practices into routine practice and healthcare policy to improve the quality and effectiveness of health services (IOM, 2012). The dissemination and implementation (D&I) lexicon includes many terms like translational research, knowledge translation, knowledge exchange, improvement science, and technology transfer. Dissemination and implementation researchers and practitioners must carefully consider strategies for translating evidence into practice to optimize health care delivery. D&I science focuses on translating knowledge into practice by facilitating stakeholder access to findings using a variety of strategies and designs that include pragmatic trials, evidence-based quality improvement, health technology assessment, systematic reviews, randomized clinical trials, and comparative effectiveness research. This collection of articles begins with broad-level perspectives such as priorities, collaboration, and IRB regulations and moves to specific examples of D&I research. Given the tremendous possibilities for D&I research, where should a nation or organization focus its resources? The manuscript by K. Stevens and J. Ovretveit addresses developing national improvement priorities for D&I research to guide researchers and funders. Results of this study suggest that, at least for the United States, the most important and urgent needs include care coordination, implementation of evidence-based practice, improving structure and clinical processes, and developing a culture of quality and safety. These types of research studies require transdisciplinary teams and an infrastructure that supports academic-practice partnerships. The article by F. Puga, K. Stevens, and D. Patel identifies best practices in developing a healthcare improvement research network that integrates various theories, methods, and perspectives of each discipline into a cohesive unit able to focus on complex research issues and topics. A companion article by D. Patel, K. Stevens, and F. Puga identifies variation in institutional review board approval process for D&I studies especially when these studies focus on quality improvement initiatives across multiple sites. Two manuscripts describe specific efforts to implement evidence-based practices. The manuscript by S. Daniels et al., describes the efforts of one Veterans Administration hospital to implement screening for dysphagia in patients who presented to the emergency department with symptoms of stroke. Multidisciplinary team cooperation and organizational support were major facilitators of this quality improvement study, while lack of adequate training perceived lack of time was seen as barriers to implementation. The manuscript by A. Wallace et al. describes the process and framework used to integrate diabetes self-management support into routine diabetes care provided in four community health clinics. The final manuscript by Y. Ogbolu et al. assessed the level of nurse compliance with evidence-based guidelines for preventing mother-to-child transmission of HIV in a resource-limited country. Although making up the greatest portion of the health care workface in most countries, educational and scope of practice barriers often hinder their effectiveness in improving health outcomes. By compiling these papers, we hope to enrich our readers with respect to the need for and variety of D&I studies. We also hope to stimulate thought for future studies to enhance the translation of evidence into practice and to improve health outcomes for populations. Deborah Vincent Marie Hastings-Tolsma Kathleen R. Stevens

Natal tooth and cultural impact on its management in a tropical neonatal unit: A Case Report

The incidence of natal tooth is uncommon and its management could be fraught with challenges. A 3 day old female presented with features of sepsis and a natal tooth. Treatment for sepsis was permitted and successfully instituted but definitive management of the natal tooth was deferred, for cultural reasons, by the parents. The case documents the occurrence of natal tooth and highlights the impact of cultural beliefs on management of some medical conditions. It underscores the need to develop the relationship between orthodox medical care and cultural beliefs, in susceptible communities, with a view to achieving optimal health care delivery.

A Role for Government: An Observation on Federal Healthcare Efforts in Prevention

A Role for Government: An Observation on Federal Healthcare Efforts in Prevention

Assessment of Commonly Available Education Materials in Heart Failure Clinics

Health literacy (HL) is an established independent predictor of cardiovascular outcomes. Approximately 90 million Americans have limited HL and read at the fifth grade level or lower. Therefore, we sought to determine the suitability and readability level of common cardiovascular patient education materials (PEM) related to heart failure and heart-healthy lifestyle. The suitability and readability of written PEMs were assessed using the suitability assessment of materials (SAM) and Fry readability formula. The SAM criteria are composed of the following categories: message content, text appearance, visuals, and layout and design. We obtained a convenience sample of 18 English-written cardiovascular PEMs freely available from major health organizations. Two reviewers independently appraised the PEMs. Final suitability scores ranged from 12% to 87%. Readability levels ranged between 3rd and 15th grade level; the average readability level was 8th grade. Ninety-four percent of the PEMs were rated either superior or adequate on text appearance, but 50% or more of the PEMs were rated inadequate on each of the other categories of the SAM criteria. Only 2 (11%) PEMs had the optimum suitability score of 70% or higher and 5th grade or lower readability level suitable for populations with limited HL. Commonly available cardiovascular PEMs used by some major healthcare institutions are not suitable for the average American patient. The true prevalence of suboptimal PEMs needs to be determined because it potentially negatively impacts optimal healthcare delivery and outcomes.

Eliciting patients’ preferences for outpatient treatment of febrile neutropenia: a discrete choice experiment

Studies have demonstrated that patients at low risk for febrile neutropenia (FN) complications can be treated safely and effectively at home. Information on patient preferences for outpatient treatment of this condition will help to optimize health care delivery to these patients. The purpose of this study was to elicit non-Hodgkin lymphoma patients' preferences on attributes related to outpatient treatment of FN. We used a self-administered discrete choice experiment questionnaire based on the attributes of out-of-pocket costs, unpaid caregiver time required daily, and probability of return to the hospital. Ten paired scenarios in which levels of the attributes were varied were presented to study patients. For each pair, patients indicated the scenario they preferred. Adjusted odds ratios (ORs) of accepting a scenario that described outpatient care for FN were estimated. Eighty-eight patients completed the questionnaire. Adjusted ORs [95 % confidence intervals] of accepting outpatient care for FN were 0.84 [0.75, 0.95] for each $10 increase in out-of-pocket cost; 0.82 [0.68, 0.99] for each 1 h increase in daily unpaid caregiver time; and 0.53 [0.50, 0.57] for each 5 % increase in probability of return to the hospital. Probability of return to the hospital was the most important attribute to patients when considering home-based care for FN. Patients considered out-of-pocket costs and unpaid caregiver time to be less important than probability of return to the hospital. This study identifies factors that could be incorporated into outpatient delivery systems for FN care to ensure adequate patient uptake and satisfaction with such programs.

Versorgung von Menschen am Lebensende

Within end-of-life care concepts, relatives of patients suffering from incurable illness are an important target group. This study aims to explore the experiences of relatives of deceased patients regarding health care delivery within the last days and weeks of life, and to work out implications for patient and relatives oriented improvement strategies. We conducted 19 qualitative interviews with bereaved relatives addressing the patient's use of health care services and satisfaction with the services, as well as communication and information. Interviews were transcribed verbatim and analyzed using qualitative content analysis. Three main categories were developed: (1) present health care delivery, e. g. positive and negative experiences concerning communication and information; (2) expectations and wishes, e. g. better support and coordination concerning discharge from hospital; (3) the relative and the dying patient, e. g. attitudes towards death and dying as well as individual limitations and resources. Overall, from the perspective of the bereaved relatives there are deficits concerning coordination of health care delivery and communication. Improving coordination of health care in particular with regard to the interfaces of outpatient and inpatient care, advanced care planning and strengthening "talking medicine" may contribute to optimize health care delivery for severely ill and dying patients and their relatives.

Optimizing Health Care Delivery by Integrating Workplaces, Homes, and Communities

In recent years, the health care reform discussion in the United States has focused increasingly on the dual goals of cost-effective delivery and better patient outcomes. A number of new conceptual models for health care have been advanced to achieve these goals, including two that are well along in terms of practical development and implementation-the patient-centered medical home (PCMH) and accountable care organizations (ACOs). At the core of these two emerging concepts is a new emphasis on encouraging physicians, hospitals, and other health care stakeholders to work more closely together to better coordinate patient care through integrated goals and data sharing and to create team-based approaches that give a greater role to patients in health care decision-making. This approach aims to achieve better health outcomes at lower cost. The PCMH model emphasizes the central role of primary care and facilitation of partnerships between patient, physician, family, and other caregivers, and integrates this care along a spectrum that includes hospitals, specialty care, and nursing homes. Accountable care organizations make physicians and hospitals more accountable in the care system, emphasizing organizational integration and efficiencies coupled with outcome-oriented, performance-based medical strategies to improve the health of populations. The ACO model is meant to improve the value of health care services, controlling costs while improving quality as defined by outcomes, safety, and patient experience. This document urges adoption of the PCMH model and ACOs, but argues that in order for these new paradigms to succeed in the long term, all sectors with a stake in health care will need to become better aligned with them-including the employer community, which remains heavily invested in the health outcomes of millions of Americans. At present, ACOs are largely being developed as a part of the Medicare and Medicaid systems, and the PCMH model is still gathering momentum and evolving among physicians. But, the potential exists for implementation of both of these concepts across a much broader community of patients. By extending the well-conceived integrative concepts of the PCMH model and ACOs into the workforce via occupational and environmental medicine (OEM) physicians, the power of these concepts would be significantly enhanced. Occupational and environmental medicine provides a well-established infrastructure and parallel strategies that could serve as a force multiplier in achieving the fundamental goals of the PCMH model and ACOs. In this paradigm, the workplace-where millions of Americans spend a major portion of their daily lives-becomes an essential element, next to communities and homes, in an integrated system of health anchored by the PCMH and ACO concepts. To be successful, OEM physicians will need to think and work innovatively about how they can provide today's employer health services-ranging from primary care and preventive care to workers' compensation and disability management-within tomorrow's PCMH and ACO models.

Invisible populations: parallels between the health of people with intellectual disability and people of a refugee background

When considering the delivery of primary health care in the community, some populations remain virtually invisible. While people with intellectual disability might seem to share few characteristics with refugees and humanitarian entrants, there are a number of difficulties that both groups share when accessing and receiving primary health care. Commonalities include communication barriers, difficulties accessing past medical records and the complexity of health needs that confront the practitioner providing health care. These issues and additional systemic barriers that prevent the delivery of optimal health care to both groups are explored. Integrated multidisciplinary care is often required for the delivery of best practice care; however, such care can be difficult for each group to access. In May 2010, the specific Medicare Health Assessment Item numbers for both of these groups were incorporated into a group of more generic Item numbers. This has resulted in a lost opportunity to enhance the evidence surrounding health care delivery to these vulnerable populations. This paper recognises the importance of health policy in leading affirmative action to ensure these populations become visible in the implementation of the National Primary Health Care Strategy.

Development and Early Evaluation of an Inter-professional Post-licensure Education Programme for Extended Practice Roles in Arthritis Care

The Advanced Clinician Practitioner in Arthritis Care (ACPAC) Program was developed to train experienced physical and occupational therapists within extended practice roles with the aim of facilitating optimal, timely, and appropriate delivery of health care to patients with arthritis. This paper presents (1) the development of the ACPAC Program and (2) performance across the programme, as well as early quantitative and qualitative changes in clinical practice roles for the 2006 through 2008 cohorts of ACPAC Program graduates (n=19). Measurement of change in skills and knowledge involved standardized baseline and end-of-programme examinations as well as self-evaluation of a number of areas of clinical competence. Practice-focused surveys issued at baseline, mid-programme, and end of programme, as well as at 6 and 12 months after graduation, evaluated the practitioners' integration of advanced knowledge and skills acquired during the ACPAC Program into their extended practice roles. Participants significantly increased their scores on examinations of clinical knowledge (p<0.001) and skills (p<0.001) from baseline through programme completion. There was an increase in frequency of performance of clinical tasks and assumption of responsibilities related to their extended practice roles from the beginning to the end of the programme. The five areas that changed in relation to these new roles were increased clinical responsibilities, efficiencies in practice settings, roles as educational leaders and mentors in the field of arthritis care, inter-professional collaboration, and improved access to care for patients with arthritis, particularly in remote areas. Graduates of the ACPAC Program have demonstrated knowledge and skills for practising in extended roles that enhance the available human health resource pool for patients with arthritis.

Journal introduction

This issue provides readers with an executive summary of an important update to the Cardiac CT Appropriate Use Criteria (AUC) by the American College of Cardiology Foundation, in collaboration with multiple societies, including the SCCT. The intent of these criteria is to guide the rational use of the procedure, namely avoidance of either underuse or overuse, and thereby leading to more optimal health care delivery and justifiable health care expenditures. Originally published in 2006, this version of the AUC represents a significant expansion of the rated criteria (increased from 37 to 93) on the basis of significant interval technical advances and clinical evidence development for cardiac CT. These advances are reflected in progression in the criteria considered appropriate for imaging and new clinical scenarios that reflect a broader range of considerations to use cardiac CT. Performance and optimal use measures represent the new reality in health care and cardiovascular imaging; therefore, although not “guidelines” per se, these criteria provide a pathway toward optimal utilization of imaging technology. I urge every imager and clinician who uses cardiac CT to not only become familiar with these criteria but also to take a personal stake in locally implementing these criteria to the best of their ability.

Inpatient Heart Failure Specialty Units

Congestive heart failure is a major public health challenge and a leading cause of hospitalization in the United States. Despite major recent advances in the treatment of this condition, morbidity and mortality rates remain unacceptably high, and readmission rates can approach 50% at 6 months. Rehospitalization rates associated with this condition pose a significant economic burden on the health care budget. The main purpose of this article is to address how utilization of multidisciplinary heart failure units for the treatment of acute heart failure can lead to optimization of health care delivery for this condition, improved clinical outcomes, decreased rehospitalization rates, and reduced health care costs. We will explore the societal impact of heart failure and economic burden of this condition, with special focus on the impact of acutely hospitalized heart failure patients. Shortcomings and windfalls in the delivery of health care for this condition will be addressed. The multiple components of care essential to successful treatment of heart failure will be discussed. The article will then discuss how development of a formal multidisciplinary inpatient heart failure disease management program will consolidate and centralize all these various components and provide for optimal delivery of health care for this condition.

Health Care Reform and the Opportunity to Implement a Family-Centered Medical Home for Children

HE PASSAGE OF THE PATIENT PROTECTION AND AFfordable Care Act (PPACA) formalized the concept of the medical home and primary care as a vitalpartofeffectivehealthcaredelivery.ThePPACA comesclosertoprovidinguniversalaccesstocareandseeks evidence-basedmodelstoimprovematernalchildhealthprograms such as home visiting, Emergency Medical Services forChildren,andcommunityhealthteamsinsupportofthe medical home system of care. Implemented correctly, the critical components of an integrated system could evolve to improve quality, efficiency, and cost-effective care that allows appropriate payment for a model of optimal health care delivery. It may be instructive to review the roots of the medical home concept and its application over decades as the family-centered medical home (FCMH).

Administrative Simplicity: An Important Component of Health Care Delivery

Administrative simplicity is an often overlooked but important component in optimizing health care delivery. The current administrative structures of most US (and international) academic medical centers have multiple, often independent parts that must negotiate and come to agreement on any new changes. Such negotiations can lead to compromised change and delayed implementations. A noncomplex administrative structure offers many advantages and can make it possible to be better at becoming better. In a simplified, integrated structure, strategic goals and cultural changes can be more easily executed across the organization. Such institutions are potentially better structured to achieve the alignment of values and priorities and to move forward once decisions are made. The authors encourage medical leaders to consider administrative simplicity when opportunities arise to reevaluate health care governance structures.

Survey of US chiropractors' perceptions about their clinical role as specialist or generalist

Objective The purpose of this study was to provide new information that describes chiropractors' professional identity relative to their perceived clinical role as specialist or generalist. Methods A pragmatic, descriptive, cross-sectional survey was performed of randomly sampled state-board licensed chiropractors in the United States during the period 2002–2003 to assess the chiropractors' perceptions of how their chiropractic patients see them, and how they see themselves, as specialist or generalist. For this exploratory study, we anchored the terms “back pain specialist,” “musculoskeletal specialist,” and “primary care generalist” to brief generic reference definitions in our survey instrument. Results Of our 2598 valid survey contacts, 1343 chiropractors returned their surveys either partially or fully completed, and a total of 720 chiropractor surveys were used in this study. Most of these chiropractors perceived that their new patients viewed them as “back pain specialists.” Chiropractors believed that their established patients (80%), more so than their new patients (58%), were likely to view them as a primary care generalist. Chiropractors described themselves as both specialist and generalist, and they expressed a greater capability to diagnose, rather than to treat, health disorders that were not musculoskeletal. Conclusion Chiropractic physician perceptions as reported in this study suggest that the nature of certain chiropractor-patient relationships may evolve profoundly over time, particularly as patients transition from new to established patients within the chiropractic practice. Understanding the complex nature of chiropractic health care provision may carry implications for advancing evidence-based chiropractic practice and clinical training, enhancing successful and comprehensive management of the complex health concerns of chiropractic patients, fostering beneficial sustained partnerships between chiropractors and their patients, and improving overall delivery of optimal integrative health care.

Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review)

To systematically review evidence bearing on the management of patients with amyotrophic lateral sclerosis (ALS). The authors analyzed studies from 1998 to 2007 to update the 1999 practice parameter. Topics covered in this section include breaking the news, multidisciplinary clinics, symptom management, cognitive and behavioral impairment, communication, and palliative care for patients with ALS. The authors identified 2 Class I studies, 8 Class II studies, and 30 Class III studies in ALS, but many important areas have been little studied. More high-quality, controlled studies of symptomatic therapies and palliative care are needed to guide management and assess outcomes in patients with ALS. Multidisciplinary clinic referral should be considered for managing patients with ALS to optimize health care delivery and prolong survival (Level B) and may be considered to enhance quality of life (Level C). For the treatment of refractory sialorrhea, botulinum toxin B should be considered (Level B) and low-dose radiation therapy to the salivary glands may be considered (Level C). For treatment of pseudobulbar affect, dextromethorphan and quinidine should be considered if approved by the US Food and Drug Administration (Level B). For patients who develop fatigue while taking riluzole, withholding the drug may be considered (Level C). Because many patients with ALS demonstrate cognitive impairment, which in some cases meets criteria for dementia, screening for cognitive and behavioral impairment should be considered in patients with ALS (Level B). Other management strategies all lack strong evidence.

Intervention studies for improving global health and health care: An important arena for epidemiologists

Marginalised populations in many low- and middle-income countries experience an increasing burden of disease, in sub-Saharan Africa to a large extent due to faltering health systems and serious HIV epidemics. Also other poverty related diseases (PRDs) are prevalent, especially respiratory and diarrhoeal diseases in children, malnutrition, maternal and perinatal health problems, tuberculosis and malaria. Daily, nearly 30,000 children under the age of 5 die, most from preventable causes, and 8,000 people die from HIV infections. In spite of the availability of powerful preventive and therapeutic tools for combating these PRDs, their implementation, especially in terms of equitable delivery, leaves much to be desired. The research community must address this tragic gap between knowledge and implementation. Epidemiologists have a very important role to play in conducting studies on diseases that account for the largest share of the global disease burden. A shift of focus of epidemiologic research towards intervention studies addressing health problems of major public health importance for disadvantaged population groups is needed. There is a need to generate an evidence-base for interventions that can be implemented on a large scale; this can result in increased funding of health promotion programs as well as enable rational prioritization and integration between different health interventions. This will require close and synergetic teamwork between epidemiologists and other professions across disciplines and sectors. In this way epidemiologists can contribute significantly to improve health and optimise health care delivery for marginalized populations.

PharmD or Needs Based Education: Which Comes First?

PharmD or Needs Based Education: Which Comes First?

The Center for Genomic Medicine at the Duke Institute for Genome Sciences & Policy: propelling genomics into clinical practice.

Until now, advances in the genomic sciences have had a minor impact on the practice of medicine. But genomic medicine has the potential to radically alter healthcare in the USA and around the world. By understanding the predictive power of patients' genomes, it should be possible to identify individuals at risk of disease and to create smarter, more effective treatments for those who are already ill. It is the mission of the Center for Genomic Medicine at the Duke Institute for Genome Sciences & Policy (NC, USA) to harness information from the human genome in order to optimize efficiency, effectiveness and success in bringing the right therapy to the right patient at the right time. In doing so, the Center has focused on the development and implementation of translational models for delivery of genomic healthcare, exploring the nature and breadth of genomic tests, novel approaches to pre- and post‑analytical care, and the design of an optimal healthcare delivery team.

Health status and quality of life of elderly persons with severe hemophilia born before the advent of modern replacement therapy.

More and more people with severe hemophilia reach an old age thanks to an effective treatment. There is no information on the health status and quality of life of elderly people with hemophilia born at a time when replacement therapy was hardly available. Italian patients with severe hemophilia, aged >or=65 years and hence born in 1942 or earlier, were compared with elderly men without bleeding disorders matched for age, sex, geography and social status. The following aspects were evaluated: concomitant illness, orthopedic status, physical functioning and cognitive status. Measurements of generic and disease-specific health-related quality of life were also obtained, together with the presence or absence of depression. Thirty-nine patients, aged 65-78 years, were investigated; 33 had hemophilia A. All patients had started regular treatment on demand only when they were already 25-30 years of age. Patients were compared with 43 men without hemophilia, aged 65-79 years. More patients with hemophilia had chronic hepatitis B and C, HIV infection and hypertension. On the other hand, their elderly peers without hemophilia were more frequently hypercholesterolemic and had more cardiovascular diseases. Most hemophiliacs had arthropathy and worse values for physical functioning, but their cognitive status was similar to that of elderly non-hemophiliacs. Hemophiliacs reported greater depression and lower health-related quality of life. Elderly patients with hemophilia have more co-morbidities and problems in daily living, but similar cognitive status as age-matched non-hemophilic peers. They have more chronic viral infections and hypertension but fewer cardiovascular diseases. These observations should help to optimize health care delivery in this increasing and neglected population of people with hemophilia.

Quality of life in patients with familial amyloidotic polyneuropathy long-term after liver transplantation

Liver transplantation aims to halt the progression of the disease in patients with familial amyloidotic polyneuropathy (FAP) caused by hereditary transthyretin-related (ATTR) amyloidosis. Insight in health-related quality of life of these transplanted FAP-patients can be of help to optimize health care delivery. The aim of this cross-sectional study was to assess the health-related quality of life of patients with FAP long-term after transplantation.Nine patients with a post-transplant follow-up of 4 years or more were included in the study. During the annual checks, health-related quality of life was measured with the Short Form-36 (SF-36). Data were compared with non-FAP transplanted patients with the same duration of follow-up and with the normal Dutch population. Pre-transplant, all patients had signs of mild to moderate peripheral polyneuropathy.The results showed that in patients with FAP health-related quality of life was stable in the first 4 years after transplantation. The domain of physical well-being at 4 years after transplantation was significantly lower compared to non-FAP transplanted patients and control Dutch population. The domain of emotional well-being was comparable with non-FAP controls. However, on most health areas patients with FAP scored lower than the non-FAP transplanted patients and the Dutch controls. After four years, the three patients with FAP with longest follow-up (9–12 years) deteriorated in all health domains, except in self-perceived mental health.This study, including only a small number of patients with FAP, shows a relatively low health-related quality of life after liver transplantation, which may deteriorate further with longer follow-up.