Faculty Bibliography

BACKGROUND:Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts. OBJECTIVE:To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context. DESIGN/METHODS:Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines. PARTICIPANTS/METHODS:15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs). MAIN MEASURES/METHODS:Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach. KEY RESULTS/RESULTS:Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts. CONCLUSIONS:Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings.

PURPOSE/UNASSIGNED:To identify rates and sociodemographic correlates of food insecurity among low-income smokers. DESIGN/UNASSIGNED:Cross-sectional analysis of baseline survey data from a randomized controlled trial (N = 403) testing a smoking cessation intervention for low-income smokers. SETTING/UNASSIGNED:Two safety-net hospitals in New York City. SAMPLE/UNASSIGNED:Current smokers with annual household income <200% of the federal poverty level. MEASURES/UNASSIGNED:Food insecurity was measured using the United States Department of Agriculture 6-item food security module. Participant sociodemographics were assessed by self-reported survey responses. ANALYSIS/UNASSIGNED:We used frequencies to calculate the proportion of smokers experiencing food insecurity and multivariable logistic regression to identify factors associated with being food insecure. RESULTS/UNASSIGNED:Fifty-eight percent of participants were food insecure, with 29% reporting very high food insecurity. Compared to married participants, separated, widowed, or divorced participants were more likely to be food insecure (adjusted odds ratio [AOR] = 2.33, 95% confidence interval [CI]: 1.25-4.33), as were never married participants (AOR = 2.81, 95% CI: 1.54-5.14). CONCLUSIONS/UNASSIGNED:food access) may be needed for low-income populations. Interventions which seek to alleviate food insecurity may benefit from targeting socially isolated smokers.

Tobacco use is rarely addressed in community mental healthcare despite high patient smoking prevalence. Community mental health centers have systems in place that could be used to comprehensively address tobacco use. This study tested feasibility of, satisfaction with, and safety of proactive tobacco treatment (tobacco outreach to offer connection to tobacco cessation treatment). Behavioral health home patients who smoke were randomly assigned to usual care (UC; N = 11) or proactive care (PC; N = 9). All participants were called 3-months post-randomization for follow-up. PC patients reported high satisfaction with the program and experienced no adverse events or mental health symptom exacerbation during treatment. PC patients reported greater reductions in cigarettes per day, more quit attempts, and more cessation medication utilization than UC patients. Proactive outreach for tobacco cessation is feasible in a behavioral health home, acceptable to patients, and may reduce smoking heaviness and promote quit attempts.

OBJECTIVES/OBJECTIVE:Guidelines recommend that smokers participate in four or more counseling sessions when trying to quit, but smokers rarely engage in multiple sessions. The "decoy effect" is a cognitive bias that can cause consumer preferences for a "target" product to change when presented with a similar but inferior product (a "decoy"). This study tested the use of a decoy to guide smokers' selection of a target number of counseling sessions. During an online survey, adult tobacco users (N = 93) were randomized to one of two groups that determined the answer choices they saw in response to a question assessing their interest in multi-session cessation counseling. Group A choose between two sessions or a "target" of five sessions. Group B was given a third "decoy" option of seven sessions. Binary logistic regression was used to compare groups on the proportion of participants selecting the "target." RESULTS:Among 90 participants with complete data, a decoy effect was not found. There was no significant difference between groups in the proportion of participants selecting the target of five sessions (47% in Group B vs. 53% in Group A; aOR = 0.76, 95%CI 0.48-1.19). Trial Registration This study was retrospectively registered at clinicaltrials.gov on December 13, 2019 (NCT04200157).

OBJECTIVE:HealthyHearts NYC was a stepped wedge randomized control trial that tested the effectiveness of practice facilitation on the adoption of cardiovascular disease guidelines in small primary care practices. The objective of this study was to identify was to identify attributes of small practices that signaled they would perform well in a practice facilitation intervention implementation. METHODS:A mixed methods multiple-case study design was used. Six small practices were selected representing 3 variations in meeting the practice-level benchmark of >70% of hypertensive patients having controlled blood pressure. Inductive and deductive approaches were used to identify themes and assign case ratings. Cross-case rating comparison was used to identify attributes of high performing practices. RESULTS:Our first key finding is that the high-performing and improved practices in our study looked and acted similarly during the intervention implementation. The second key finding is that 3 attributes emerged in our analysis of determinants of high performance in small practices: (1) advanced use of the EHR; (2) dedicated resources and commitment to quality improvement; and (3) actively engaged lead clinician and office manager. CONCLUSIONS:These attributes may be important determinants of high performance, indicating not only a small practice's capability to engage in an intervention but possibly also its readiness to change. We recommend developing tools to assess readiness to change, specifically for small primary care practices, which may help external agents, like practice facilitators, better translate intervention implementations to context.

BACKGROUND:People with a psychiatric diagnosis smoke at high rates, yet are rarely treated for tobacco use. Health care systems often use a 'no treatment' default for tobacco, such that providers must actively choose (opt-in) to treat their patients who express interest in quitting. Default bias theory suggests that opt-in systems may reinforce the status quo to not treat tobacco use in psychiatry. We aim to conduct a pilot study testing an opt-out system for implementing a 3A's (ask, advise, assist) tobacco treatment model in outpatient psychiatry. METHODS:We will use a mixed-methods, cluster-randomized study design. We will implement a tobacco use clinical reminder for outpatient psychiatrists at the VA New York Harbor Healthcare System. Psychiatrists (N = 20) will be randomized 1:1 to one of two groups: (1) Opt-In Treatment Approach: Psychiatrists will receive a reminder that encourages them to offer cessation medications and referral to cessation counseling; or (2) Opt-Out Treatment Approach: Psychiatrists will receive a clinical reminder that includes a standing cessation medication order and a referral to cessation counseling that will automatically generate unless the provider cancels. Prior to implementation of the reminders, we will hold a 1-hour training on tobacco treatment for psychiatrists in both arms. We will use VA administrative data to calculate the study's primary outcomes: 1) the percent of smokers prescribed a cessation medication and 2) the percent of smokers referred to counseling. During the intervention period, we will also conduct post-visit surveys with a cluster sample of 400 patients (20 per psychiatrist) to assess psychiatrist fidelity to the 3 A's approach and patient perceptions of the opt-out system. At six months, we will survey the clustered patient sample again to evaluate the study's secondary outcomes: 1) patient use of cessation treatment in the prior 6 months and 2) self-reported 7-day abstinence at 6 months. At the end of the intervention period, we will conduct semi-structured interviews with 12-14 psychiatrists asking about their perceptions of the opt-out approach. DISCUSSION/CONCLUSIONS:This study will produce important data on the potential of opt-out systems to overcome barriers in implementing tobacco use treatment in outpatient psychiatry. TRIAL REGISTRATION/BACKGROUND:Clinicaltrials.gov Identifier NCT04071795 (registered August 28, 2019). https://www.clinicaltrials.gov/ct2/show/NCT04071795.

Few studies have examined factors that facilitate recruitment of small independent practices (SIPs) (<5 full-time clinicians) to participate in research and methods for optimizing retention. The authors analyzed qualitative data (eg, recruiter's field notes and diary entries, provider interviews) to identify barriers and facilitators encountered in recruiting and retaining 257 practices in HealthyHearts New York City (NYC). This study was a stepped-wedge randomized controlled trial that took place 2015 through 2018 across 5 boroughs in NYC. Three main factors facilitated rapid recruitment: (1) a prior well-established relationship with the local health department, (2) alignment of project goals with practice priorities, and (3) providing appropriate monetary incentives. Retention was facilitated through similar mechanisms and an ongoing multifaceted communication strategy. This article identifies specific strategies that enhance recruitment of SIPs and fills gaps in knowledge about factors that influence retention in the context of a design that requires waiting to receive the intervention.

Introduction: The use of electronic cigarettes (e-cigarettes) in smokers with mental health conditions (MHC) is not well understood. Aims: This study aims to compare e-cigarette users and non-users among veteran smokers with MHC to characterize differences in smoking behavior, motivation to quit, psychological distress, primary psychiatric diagnosis, and other factors. Methods: Baseline survey data were used from a randomized smoking cessation trial enrolling smokers with MHC from four Veterans Health Administration hospitals. Participants were categorized as current, former (having ever tried an e-cigarette), or never e-cigarette users. Pearson's chi2 and

INTRODUCTION/BACKGROUND:Smoking disproportionately affects individuals with psychiatric diagnoses. Providers can play a role in reducing tobacco-related morbidity among people with a psychiatric diagnosis by routinely screening and treating all patients for tobacco use. This study seeks to identify rates of tobacco screening, counseling, and medication orders during outpatient visits with adults who have a psychiatric diagnosis. METHODS:Data from the 2012-2015 National Ambulatory Medical Care Survey were examined to calculate the proportion of visits with people who have a psychiatric diagnosis that included tobacco screening, counseling, or smoking-cessation medications. Logistic regression was used to identify patient and visit factors associated with tobacco screening and treatment. All analyses were conducted in 2018. RESULTS:Seventy-two percent of visits included tobacco screening, 23% of visits with tobacco users included cessation counseling, and 4% of visits with tobacco users included a cessation medication order. Visits were more likely to include tobacco screening if they were for a nonpsychiatric condition, were >30 minutes, or were with a primary care physician (p<0.05). Visits were less likely to include tobacco screening if they were with a black, non-Hispanic patient or patient with Medicaid (p<0.05). Visits were more likely to include cessation counseling if they were for a nonpsychiatric condition (p<0.05), and were less likely to include counseling if they were with a Hispanic or self-pay patient (p<0.05). CONCLUSIONS:There is still room for improvement in providing equitable treatment for people with psychiatric conditions for smoking, particularly in nonprimary settings.

PURPOSE/OBJECTIVE:Small independent primary care practices (SIPs) often lack the resources to implement system changes. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality, studied the effectiveness of practice facilitation to improve cardiovascular disease- related care in 257 SIPs. We sought to understand SIP clinicians' perspectives on the benefits of practice facilitation. METHODS:We conducted in-depth interviews with 19 SIP clinicians enrolled in HealthyHearts NYC. Interviews were transcribed and coded using deductive and inductive approaches. To understand whether the perceived benefits of practice facilitation differ based on the availability of internal staff for quality improvement (QI), we compared themes pertaining to benefits between practices with 3 or fewer office staff vs more than 3 office staff. RESULTS:Clinicians perceived 2 main benefits of practice facilitation. First, facilitators served as a connection to the external health care environment for SIPs, often through teaching and information sharing. Second, facilitators provided electronic health record (EHR)/data expertise, often by teaching functionality and completing technical assistance and tasks. SIPs with more than 3 office staff felt that facilitators provided benefits primarily through teaching, whereas SIPs with 3 or fewer staff felt that facilitators also provided hands-on support. At the intersections of these benefits, there emerged 3 central practice facilitation benefits: (1) creating awareness of quality gaps, (2) connecting practices to information, resources, and strategies, and (3) optimizing the EHR for QI goals. CONCLUSIONS:SIP clinicians perceived practice facilitation to be an important resource for connecting their practice to the external health care environment and resources, and helping their practice build QI capacity through teaching, hands-on support, and EHR-driven solutions.