The Veterans Affairs experience: comparative effectiveness research in a large health system

Comparative effectiveness research is a tool to use in achieving patient-centered, high-value health care. However, applying the results to individual patients and health systems raises unique issues. Here, we review lessons learned by the Veterans Health Administration (VHA) in developing and implementing the research in a large integrated health system. Decision makers should examine whether individual studies apply to diverse populations, align tools and incentives to adopt evidence-based practices, and consider both the patient and population perspectives. A key challenge remains how to incorporate comparative evidence and patient values into busy clinical practices.     

Optimizing Disease Management of Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a major public health problem worldwide. It is the fourth leading cause of chronic morbidity and mortality in the US, and is projected to rank seventh in burden of disease worldwide by 2020. In contrast with a number of chronic diseases, COPD is most often associated with one or more co-morbid conditions, and this requires a complexity of care that demands an even higher level of coordination of care. The coordination that characterizes disease management enables physicians to identify and treat all co-morbid conditions that, if not addressed, could seriously compromise the care of COPD. The requirements for high-quality 21st century care are stringent; some examples are (i) patient-centered care; (ii) adherence to evidence-based medicine that seeks standardization of care; (iii) integration of myriad medical disciplines and the care of multiple physicians; (iv) patient empowerment through collaborative self-management and shared decision making; (v) ongoing home monitoring and feedback to allow for early intervention; and (vi) formalized efforts to improve patient-physician and patient-nurse communication.The true value of disease management resides in its capacity to improve patient care, based as it is on heightened physician communication, evidence-based medicine, and adherence to guidelines, the principle of patient-centered care that facilitates collaborative self-management and concern with patient satisfaction. We provide evidence that patients want and respond to patient-centered care — care that is not technology, doctor, hospital, nor disease centered. Care that encourages patient participation in the establishment and implementation of care, respects the patient’s desire for information, seeks to understand and respond to patient emotional needs, and strengthens the patient-physician relationship.     

Integrating Client and Clinician Perspectives on Psychotropic Medication Decisions: Developing a Communication-Centered Epistemic Model of Shared Decision Making for Mental Health Contexts

Shared decision making (SDM) interventions aim to improve client autonomy, information sharing, and collaborative decision making, yet implementation of these interventions has been variably perceived. Using interviews and focus groups with clients and clinicians from mental health clinics, we explored experiences with and perceptions about decision support strategies aimed to promote SDM around psychotropic medication treatment. Using thematic analysis, we identified themes regarding beliefs about participant involvement, information management, and participants’ broader understanding of their epistemic expertise. Clients and clinicians highly valued client-centered priorities such as autonomy and empowerment when making decisions. However, two frequently discussed themes revealed complex beliefs about what that involvement should look like in practice: (a) the role of communication and information exchange and (b) the value and stability of clinician and client epistemic expertise. Complex beliefs regarding these two themes suggested a dynamic and reflexive approach to information management. Situating these findings within the Theory of Motivated Information Management, we discuss implications for conceptualizing SDM in mental health services and adapt Siminoff and Step’s Communication Model of Shared Decision Making (CMSDM) to propose a Communication-centered Epistemic Model of Shared Decision Making (CEM-SDM).     

Evaluating decision aids – where next?

Decision aids have been developed to help patients become involved in decision‐making about their individual health care. During the evaluation of a particular decision aid in maternity care – a set of 10 ‘Informed Choice’ leaflets – we considered the lessons learnt for evaluation of decision aids in the future. Decision aids have been tested mainly in explanatory trials and have been found to be effective. We argue that existing decision aids should be subjected to more pragmatic trials to test their effectiveness in the real world. The small amount of evidence on their use in the real world shows that they face challenges, resulting in poor implementation. Therefore, we propose that implementation strategies are developed which take heed of the findings of research on getting evidence into practice, and in particular address structural barriers such as the lack of time available to health professionals. We recommend that these ‘decision aid implementation packages’ are developed in conjunction with both health professionals and patients, and identify and address potential barriers to both the delivery of patient involvement in decision‐making, and the use of decision aids, in the real world. These ‘packages’ can then be submitted to pragmatic evaluation.     

Concepts and Instruments for Patient-Reported Outcome Assessment in Celiac Disease: Literature Review and Experts’ Perspectives

BackgroundIn diseases where there is a large subjective component, such as celiac disease (CD), patient reported-outcomes (PRO) endpoints are highly relevant. However, there is a gap in knowledge about which PRO endpoints and instruments should be used for clinical trials for treatment of celiac disease.ObjectivesTo identify patient-centered symptom, impact, and health-related quality of life (HRQoL) concepts in CD and relevant PRO instruments, and to gather expert input on concepts and instruments to inform selection of PRO endpoints for use in clinical trials of new CD treatments.MethodsA targeted literature review was conducted to identify symptom, impact, and HRQoL concepts, including those captured in PROs further reviewed against U.S. Food and Drug Administration standards for development and validation as endpoints. US and European clinicians, payers, and a patient advocate (n = 21) were interviewed to assess the identified concepts’ relative importance in measuring treatment benefit and to gauge the value of potential PROs as endpoints for market access/reimbursement.ResultsThirty-four published studies were identified: 27 elucidated patient-centered concepts and 7 detailed the development or validation of PRO instruments. The Celiac Disease Symptom Diary and Celiac Disease Patient Reported Outcome instrument were deemed most appropriate for use as endpoints; however, each had limitations related to conceptual coverage, evidence for measurement properties, and feasibility for use in clinical trials. Experts reported gastrointestinal symptoms as most important to treat, with extra-intestinal symptoms burdensome from the patient perspective as well. Payers emphasized measuring both frequency and severity of symptoms and targeting patients nonresponsive to the gluten-free diet for treatment.ConclusionsWith emerging treatment options for CD, further work is needed to operationalize PRO symptom endpoints that are meaningful to patients, valued by payers, and acceptable to regulators in demonstrating efficacy.     

Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers

ABSTRACTEfforts to redesign primary care require multiple supports. Two potential members of the primary care team—practice facilitator and care manager—can play important but distinct roles in redesigning and improving care delivery. Facilitators, also known as quality improvement coaches, assist practices with coordinating their quality improvement activities and help build capacity for those activities—reflecting a systems-level approach to improving quality, safety, and implementation of evidence-based practices. Care managers provide direct patient care by coordinating care and helping patients navigate the system, improving access for patients, and communicating across the care team. These complementary roles aim to help primary care practices deliver coordinated, accessible, comprehensive, and patient-centered care.Key Words: care coordination, practice facilitation, primary care, patient-centered care, quality improvement     

Front-Line Hospice Staff Perceptions of Barriers and Opportunities to Discussing Advance Care Planning With Hospice Patients and Their Families

ObjectivesTo understand the facilitators and barriers to hospice staff engagement of patients and surrogates in advance care planning (ACP) conversations.DesignQualitative study conducted with purposive sampling and semistructured interviews using ATLAS.ti software to assist with template analysis.Settings and ParticipantsParticipants included 51 hospice professionals (31 clinicians, 13 leaders, and 7 quality improvement administrators) from 4 geographically distinct nonprofit US hospices serving more than 2700 people.MeasuresInterview domains were derived from the implementation science framework of Capability, Opportunity, Motivation, and Behavior (COM-B), with additional questions soliciting recommendations for behavior change. Differences in themes were reconciled by consensus. The facilitator, barrier, and recommendation themes were organized within the COM-B framework.ResultsCapability was facilitated by interdisciplinary teamwork and specified clinical staff roles and inhibited by lack of self-perceived skill in engaging in ACP conversations. Opportunities for ACP occurred during admission to hospice, acute changes, or deterioration in patient condition. Opportunity-related environmental barriers included time constraints such as short patient stay in hospice and workload expectations that prevented clinicians from spending more time with patients and families. Motivation to discuss ACP was facilitated by the employee’s goal of providing personalized, patient-centered care. Implicit assumptions about patients’ and families’ preferences reduced staff’s motivation to engage in ACP. Hospice staff made recommendations to improve ACP discussions, including training and modeling practice sessions, earlier introduction of ACP concepts by clinicians in prehospice settings, and increasing workforce diversity to reflect the patient populations the organizations want to reach and cultural competency.Conclusions and ImplicationsEven hospice staff can be uncomfortable discussing death and dying. Yet staff were able to identify what worked well. Solutions to increase behavior of ACP engagement included staff training and modeling practice sessions, introducing ACP prior to hospice, and increasing workforce diversity to improve cultural competency.     

Emergency Department Care Transitions for Patients With Cognitive Impairment: A Scoping Review

ObjectivesWe aimed to describe emergency department (ED) care transition interventions delivered to older adults with cognitive impairment, identify relevant patient-centered outcomes, and determine priority research areas for future investigation.DesignSystematic scoping review.Setting and ParticipantsED patients with cognitive impairment and/or their care partners.MethodsInformed by the clinical questions, we conducted systematic electronic searches of medical research databases for relevant publications following published guidelines. The results were presented to a stakeholder group representing ED-based and non-ED-based clinicians, individuals living with cognitive impairment, care partners, and advocacy organizations. After discussion, they voted on potential research areas to prioritize for future investigations.ResultsFrom 3848 publications identified, 78 eligible studies underwent full text review, and 10 articles were abstracted. Common ED-to-community care transition interventions for older adults with cognitive impairment included interdisciplinary geriatric assessments, home visits from medical personnel, and telephone follow-ups. Intervention effects were mixed, with improvements observed in 30-day ED revisit rates but most largely ineffective at promoting connections to outpatient care or improving secondary outcomes such as physical function. Outcomes identified as important to adults with cognitive impairment and their care partners included care coordination between providers and inclusion of care partners in care management within the ED setting. The highest priority research area for future investigation identified by stakeholders was identifying strategies to tailor ED-to-community care transitions for adults living with cognitive impairment complicated by other vulnerabilities such as social isolation or economic disadvantage.Conclusions and ImplicationsThis scoping review identified key gaps in ED-to-community care transition interventions delivered to older adults with cognitive impairment. Combined with a stakeholder assessment and prioritization, it identified relevant patient-centered outcomes and clarifies priority areas for future investigation to improve ED care for individuals with impaired cognition, an area of critical need given the current population trends.     

Interprofessional Models for Shared Decision Making: The Role of the Health Care Chaplain

Shared decision making (SDM) is a central component of patient-centered care; however, a minimal amount is known about what health care chaplains contribute to this process. Data from 463 full-time chaplains practicing in the United States collected by an online survey was analyzed using SPSS 26 for bivariate and multivariate logistical regressions to identify variables impacting chaplain integration into SDM. Coding of free text responses yielded multiple domains for chaplain contributions and barriers. Thirty-eight percent of chaplains reported being often or frequently integrated into health care team discussions regarding medical decisions, with years of professional experience, time spent supporting the emotional processing of medical decisions, and being well-prepared as the strongest predictors for high integration. Qualitative analysis yielded a multifaceted picture that includes chaplain attention to the impact religion has on decision making, a focus on the patient story, and chaplains as mediators between patients, families, and the health care team. The full integration of chaplains into SDM will require education of the interdisciplinary team regarding the scope of chaplain knowledge and skills, as well as organizational level changes in chaplain to patient ratios and coverage models. In this era of increased fragmentation of health care provision and advancing complexity of medical decision making, models of Interprofessional Shared Decision Making (IP-SDM) such as the one proposed here that appreciate the specialized knowledge and skills of each member of the health care team hold promise for enhancing patient-centered care.     

A Paradoxical and Persistent Pneumonitis

Abstract

Despite increased awareness of the risks to patients within the health care system, there has been little improvement in patient safety, with 1 in 7 patients experiencing an adverse event during hospitalization. Patients are exposed to harm not only through medical errors but also by physicians' failure to adhere to evidence-based best practices, as patients receive recommended therapies only half of the time. Although much research has been devoted to developing new therapies, little time has been spent investigating the science of health care delivery. We developed 2 models for improving health care delivery that have been successfully utilized in the Michigan Keystone Project to eliminate catheter-related bloodstream infections. The first is the Comprehensive Unit-Based Safety Program (CUSP), which is aimed at changing the culture of safety and provides a framework for addressing patient safety issues at a local level. CUSP takes advantage of local wisdom to identify potential patient harms and create individualized solutions. The second is the Translating Evidence Into Practice (TRIP) model, which evaluates best practices at a hospital or hospital system level, and then creates strategies for implementation at a local level. TRIP seeks to identify barriers to implementation of best-practice medicine and standardize care over multiple care units. Components of the 2 programs are not mutually exclusive and both can be used to mitigate potential patient harms.     

Informing Patient-Centered Care Through Stakeholder Engagement and Highly Stratified Quantitative Benefit–Harm Assessments

ObjectivesIn a previous project aimed at informing patient-centered care for people with multiple chronic conditions, we performed highly stratified quantitative benefit–harm assessments for 2 top priority questions. In this current work, our goal was to describe the process and approaches we developed and to qualitatively glean important elements from it that address patient-centered care.MethodsWe engaged patients, caregivers, clinicians, and guideline developers as stakeholder representatives throughout the process of the quantitative benefit–harm assessment and investigated whether the benefit–harm balance differed based on patient preferences and characteristics (stratification). We refined strategies to select the most applicable, valid, and precise evidence.ResultsTwo processes were important when assessing the balance of benefits and harms of interventions: (1) engaging stakeholders and (2) stratification by patient preferences and characteristics. Engaging patients and caregivers through focus groups, preference surveys, and as co-investigators provided value in prioritizing research questions, identifying relevant clinical outcomes, and clarifying the relative importance of these outcomes. Our strategies to select evidence for stratified benefit–harm assessments considered consistency across outcomes and subgroups. By quantitatively estimating the range in the benefit–harm balance resulting from true variation in preferences, we clarified whether the benefit–harm balance is preference sensitive.ConclusionsOur approaches for engaging patients and caregivers at all phases of the stratified quantitative benefit–harm assessments were feasible and revealed how sensitive the benefit–harm balance is to patient characteristics and individual preferences. Accordingly, this sensitivity can suggest to guideline developers when to tailor recommendations for specific patient subgroups or when to explicitly leave decision making to individual patients and their providers.     

Patient-Centered Care for Women: Delphi Consensus on Evidence-Derived Recommendations

ObjectivePatient-centered care (PCC) could reduce gender inequities in quality of care. Little is known about how to implement patient-centered care for women (PCCW). We aimed to generate consensus recommendations for achieving PCCW.MethodsWe used a 2-round Delphi technique. Panelists included 21 women of varied age, ethnicity, education, and urban/rural residence; and 21 health professionals with PCC or women’s health expertise. Panelists rated recommendations, derived from prior research and organized by a 6-domain PCC framework, on a 7-point Likert scale in an online survey. We used summary statistics to report response frequencies and defined consensus as when ≥85% panelists chose 5 to 7.ResultsThe response rate was 100%. In round 1, women and professionals retained 46 (97.9%) and 42 (89.4%) of 47 initial recommendations, respectively. The round 2 survey included 6 recommendations for women and 5 recommendations for professionals (did not achieve consensus in round 1 or were newly suggested). In round 2, women retained 2 of 6 recommendations and professionals retained 3 of 5 recommendations. Overall, 49 recommendations were generated. Both groups agreed on 44 (94.0%) recommendations (13 retained by 100% of both women and clinicians): fostering patient-physician relationship (n = 11), exchanging information (n = 10), responding to emotions (n = 4), managing uncertainty (n = 5), making decisions (n = 8), and enabling patient self-management (n = 6).ConclusionThe recommendations represent the range of PCC domains, are based on evidence from primary research, and reflect high concordance between women and professional panelists. They can inform the development of policies, guidelines, programs, and performance measures that foster PCCW.     

The primary prevention of heart disease in women through health behavior change promotion in primary care.

PURPOSE: To summarize recent evidence-based recommendations for physical activity promotion, dietary improvement, and tobacco cessation from the U.S. Preventive Services Task Force (USPSTF) and the Task Force on Community Preventive Services (CTF), and examine their applicability to the primary prevention of cardiovascular disease (CVD) in women through primary care interventions. METHODS: For the behaviors cited, USPSTF and CTF recommendations and their associated systematic evidence reviews (SERs) were retrieved. Individual articles from the USPSTF healthy diet and physical activity SERs that met our inclusion criteria were systematically examined to determine the applicability of this research to women. We supplemented findings from these sources with comprehensive federal research summaries and SERs from focused searches of systematic review databases relevant to primary CVD prevention in women through healthy behavior change. MAIN FINDINGS: The USPSTF strongly recommends primary care interventions for tobacco cessation. Strong CTF recommendations for multicomponent systems supports for clinicians, telephone support for quitters, and reduced patient costs for effective cessation therapies guide complementary approaches to assist clinicians. The USPSTF recommends intensive behavioral dietary counseling by specialists for high-risk CVD patients, but found insufficient evidence to recommend for routine healthy diet or physical activity promotion in primary care. The evidence base for these recommendations generally applies to women. Better reporting of gender and minority subgroup outcomes will assist more in-depth understanding of potential differences in either the processes or outcomes of behavior change interventions. CONCLUSIONS: Primary care clinicians, including obstetrician-gynecologists, can contribute to preventing CVD in women through implementing credible evidence-based recommendations for clinical interventions in tobacco and healthy diet. Researchers can further our understanding of gender-specific issues in healthy behavior interventions by reporting process and outcome data for gender and minority subgroups.     

Patient-centeredness of integrated care programs for people with multimorbidity. Results from the European ICARE4EU project

IntroductionThis paper aims to support the implementation of patient-centered care for people with multimorbidity in Europe, by providing insight into ways in which patient-centeredness is currently shaped in integrated care programs for people with multimorbidity in European countries.MethodsIn 2014, expert organizations in 31 European countries identified 200 integrated care practices (‘programs’) in 25 countries of which 123 were included in our study. Managers of 112 programs from 24 countries completed a questionnaire about characteristics and results of the program, including questions on elements of patient-centeredness. Eight programs that were considered especially innovative or promising were analyzed in depth.ResultsPrograms used various methodologies to involve people with multimorbidity in decision-making, such as motivational interviewing and narrative counseling techniques. In 79 programs individual care plans were developed together with patients. Few programs had already been systematically evaluated, but in one program it was shown that working with individual care plans based on patients’ goals and resources resulted in increased patient satisfaction with care. Various barriers to deliver patient-centered care were reported, including inadequate knowledge and skills of both patients and professionals.ConclusionIn many European countries innovative approaches are applied to increase patient-centeredness of care for people with multimorbidity. To assess their potential benefits and conditions for implementation, thorough process and outcome evaluations of programs are urgently needed.     

Major policy changes for primary care: potential lessons for the US New Model of family medicine from the quality and outcomes framework in the United Kingdom

The Future of Family Medicine project in the United States has identified a series of core values and a New Model of practice for family medicine aiming to transform the health and health care of the nation. There are, however, few empirical examples of its effectiveness and acceptability in practice. Recent experiences of changes to primary health care in the United Kingdom (UK), particularly the introduction of the Quality and Outcomes Framework, which rewards practices for delivering evidence-based care, may provide some useful lessons for practitioners and policy makers as they implement aspects of the New Model. In this paper, the authors, who lead the Expert Review of the Quality and Outcomes Framework, critique the five characteristics of the New Model that offer the most relevant learning points for both health care systems and reflect on lessons for both clinicians and policy makers, highlighted by the experience of implementing policy change in the UK. They suggest that incremental implementation, underpinned by robust pilot data and in-depth understanding of the influence of motivation on performance, are key and conclude that sharing issues that have worked well, and less well, are important in helping both countries develop good quality patient care.