Faculty Bibliography

BACKGROUND:There is no commonly accepted comprehensive framework for describing the practical specifics of external support for practice change. Our goal was to develop such a taxonomy that could be used by both external groups or researchers and health care leaders. METHODS:The leaders of 8 grants from Agency for Research and Quality for the EvidenceNOW study of improving cardiovascular preventive services in over 1500 primary care practices nationwide worked collaboratively over 18 months to develop descriptions of key domains that might comprehensively characterize any external support intervention. Combining literature reviews with our practical experiences in this initiative and past work, we aimed to define these domains and recommend measures for them. RESULTS:The taxonomy includes 1 domain to specify the conceptual model(s) on which an intervention is built and another to specify the types of support strategies used. Another 5 domains provide specifics about the dose/mode of that support, the types of change process and care process changes that are encouraged, and the degree to which the strategies are prescriptive and standardized. A model was created to illustrate how the domains fit together and how they would respond to practice needs and reactions. CONCLUSIONS:This taxonomy and its use in more consistently documenting and characterizing external support interventions should facilitate communication and synergies between 3 areas (quality improvement, practice change research, and implementation science) that have historically tended to work independently. The taxonomy was designed to be as useful for practices or health systems managing change as it is for research.

BACKGROUND:Digital diabetes prevention programs (dDPPs) are effective behavior change tools to prevent disease progression in patients at risk for diabetes. At present, these programs are poorly integrated into existing health information technology infrastructure and clinical workflows, resulting in barriers to provider-level knowledge of, interaction with, and support of patients who use dDPPs. Tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient engagement and adherence to these programs and improved health outcomes. OBJECTIVE:This study aims to use a rigorous, user-centered design (UCD) methodology to develop a theory-driven system that supports patient engagement with dDPPs and their primary care providers with their care. METHODS:at 6 and 12 months. Secondary outcomes will be patient engagement (use and activity) in the dDPP. The mediator variables (self-efficacy, digital health literacy, and patient-provider relationship) will be measured. RESULTS:The project was initiated in 2018 and funded in September 2019. Enrollment and data collection for phase 1 began in September 2019 under an Institutional Review Board quality improvement waiver granted in July 2019. As of December 2020, 27 patients have been enrolled and first results are expected to be submitted for publication in early 2021. The study received Institutional Review Board approval for phases 2 and 3 in December 2020, and phase 2 enrollment is expected to begin in early 2021. CONCLUSIONS:Our findings will provide guidance for the design and development of technology to integrate dDPP platforms into existing clinical workflows. This will facilitate patient engagement in digital behavior change interventions and provider engagement in patients' use of dDPPs. Integrated clinical tools that can facilitate patient-provider interaction around dDPPs may contribute to improved patient adherence to these programs and improved health outcomes by addressing barriers faced by both patients and providers. Further evaluation with pilot testing and a clinical trial will assess the effectiveness and implementation of these tools. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov NCT04049500; https://clinicaltrials.gov/ct2/show/NCT04049500. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)/UNASSIGNED:DERR1-10.2196/26750.

Little research has examined the health-related social needs of emergency department (ED) patients who have HIV. We surveyed a random sample of public hospital ED patients and compared the social needs of patients with and without HIV. Social needs were high among all ED patients, but patients with HIV reported significantly higher levels of food insecurity (65.0% vs. 50.3%, p = 0.01) and homelessness or living doubled up (33.8% vs. 21.0%, p < 0.01) than other patients. Our findings suggest the importance of assessing social needs in ED-based interventions for patients with HIV.

Background/UNASSIGNED:We explored characteristics and beliefs associated with e-cigarette use patterns among cigarette smokers requiring inpatient detoxification for opioid and/or alcohol use disorder(s). Methods/UNASSIGNED:-test statistics, and logistic regression models were used. Results/UNASSIGNED: Conclusions/UNASSIGNED:E-cigarette use seems to be appealing to a small proportion of cigarette smokers with SUD. Although, dual smokers seem to use e-cigarettes for its cessation premise, they don't appear to be actively seeking to quit. E-cigarettes may offer a more effective method for harm reduction, further evaluation of incorporating it within smoking cessation protocols among patients in addiction treatment is needed.

Low levels of engagement in implementation science (IS) among health researchers is a multifaceted issue. With the aim of guiding efforts to increase engagement in IS research, we sought to identify barriers to engagement in IS within the health research community. We performed an online survey of health researchers in the United States in 2018. Basic science researchers were excluded from the sample. IS engagement was measured by self-reported conduct of or collaboration on an IS study in the past 5 years. Potential barriers tested were (a) knowledge and awareness of IS, (b) attitudes about IS research, (c) career benefits of IS, (d) research community support, and (e) research leadership support. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics and potential barriers as predictors of IS engagement. Of the 1,767 health researchers, 49.7% indicated they engaged in an implementation study. Being able to define IS (aOR 3.42, 95%CI 2.68-4.36, p < .001) and having attended IS training (aOR 3.77, 95%CI 2.96-4.81, p < .001) were associated with engaging in IS research. Among other potential barriers tested, perceptions that engaging in IS would not be good for their career (aOR 0.29, 95%CI 0.2-0.41, p < .001) was strongly associated with decreased engagement in IS research. Efforts to increase researcher familiarity with IS methods and foster support for IS within research communities, along with decreasing barriers to funding and publishing, are likely to be most effective for increasing engagement in IS research.

Background/UNASSIGNED:Implementation science (IS) has the potential to serve an important role in encouraging the successful uptake of evidence-based interventions. The current state of IS awareness and engagement among health researchers, however, is relatively unknown. Methods/UNASSIGNED:To determine IS awareness and engagement among health researchers, we performed an online survey of health researchers in the USA in 2018. Basic science researchers were excluded from the sample. Engagement in and awareness of IS were measured with multiple questionnaire items that both directly and indirectly ask about IS methods used. Unrecognized IS engagement was defined as participating in research using IS elements and not indicating IS as a research method used. We performed simple logistic regressions and tested multivariable logistic regression models of researcher characteristics as predictors of IS engagement. Results/UNASSIGNED:< 0.001). Conclusion/UNASSIGNED:Overall, awareness of IS is high among health researchers, yet there is also a high prevalence of unrecognized IS engagement. Efforts are needed to further disseminate what constitutes IS research and increase IS awareness among health researchers.

[This corrects the article DOI: 10.1186/s43058-020-00027-3.].

Research Objective: Studies have found that race/ethnicity concordance between patients and providers improves medication adherence among patients with hypertension and single CVD outcomes (eg, blood pressure control). Our objective was to examine the association of patient-physician race/ethnicity concordance on adherence to the Million Hearts "ABCS" CVD guidelines: (A) aspirin when indicated, (B) blood pressure control, (C) cholesterol management, and (S) smoking screening and cessation. To the best of our knowledge, this is the first study to examine the impact of race/ ethnicity concordance on guideline adherence to multiple CVD outcome measures.
Study Design: This study was part of HealthyHearts NYC, a stepped-wedge cluster randomized controlled trial funded through AHRQ's EvidenceNOW initiative to test the effectiveness of practice facilitation on helping primary care practices adhere to CVD guidelines. The main outcomes were the Million Hearts' ABCS measures. Two additional measures were created: (a) proportion of patients who use tobacco who received a cessation intervention (smokers counseled) and (b) a composite measure that assessed the proportion of patients meeting treatment targets for A, B, and C (ABC composite). Practice-level outcome data were extracted for thirteen quarters from practices' electronic health record (EHR) systems, encompassing the control, intervention, and follow-up periods of the intervention. Patient-physician race/ethnicity concordance was calculated using patient race/ethnicity data extracted from the practices' EHR and physician race/ethnicity data collected via a Provider Survey. The concordance measure was calculated as the proportion of patients with the same race/ethnicity as the physician, for example, if practice is led by an Asian physician, and patients are 33% non-Hispanic white, 5% non-Hispanic black, 5% Hispanic, and 57% Asian, the concordance is 0.57. Population Studied: 211 small primary care practices in NYC. Principal Findings: 57.7% of Hispanic, 53.6% of black, 73.6% of Asian, 74.2% of non-Hispanic white, and 24.1% of Hawaiian/Pacific Islander patients had the same race/ethnicity as their physicians. 44.7% of physicians had the same race/ethnicity as at least 70% of their patients. Patient-physician race/ethnicity concordance was associated with adherence to four of our six outcome measures: aspirin (IRR = 1.08, 95% CI: 1.03-1.14, P < .001); blood pressure (IRR = 1.09, 95% CI: 1.07-1.12, P < .001); smoking screening and cessation (IRR = 1.06, 95% CI: 1.04-1.08, P < .001); and ABC composite (IRR = 1.42, 95% CI: 1.33-1.52, P < 0.001). We did not find an association for race/ethnicity concordance with Cholesterol and Smokers Counseled.
Conclusion(s): Increasing opportunities for patient-physician race/ ethnicity concordance may improve adherence to CVD guidelines. The largest improvement was observed in the ABC Composite measure, suggesting that patient-physician race/ethnicity concordance is particularly important for managing medically complex patients who have multiple chronic diseases. Implications for Policy or Practice: Health policy should fund programs that support the recruitment and retention of a wide diversity of students and faculty to increase the level of concordance in patient-clinician encounters. Policy makers may also want to consider legislation to help support or protect small practices that predominantly serve communities of color, where a large proportion of the physicians may be racially/ ethnically concordant with the patient population. Medical education programs should incorporate patient-physician communication training to minimize gaps potentially created by race/ethnicity discordance

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.