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Specific Interventions for Implementing a Patient-Centered Approach to TB Care in Low-Incidence Cities.

ABSTRACT: Background: According to the latest Guidelines from the World Health Organization, there is an increasing need for patient-centered tuberculosis disease management given the socio-economic factors influencing the tuberculosis epidemic. In the present study, we aimed to study TB in Barcelona city from an anthropological point of view and to devise a series of specific proposals to implement a patient-centered approach in our setting. Methods: We carried out a qualitative study using an anthropological approach in Barcelona in the period between November 2017 and November 2018 and proposed specific interventions based on our observations. Results: In practice, in our environment (a low-incidence European country where tuberculosis tends to present in patients with multiple social problems), and despite the goodwill of the care teams, there are no established and stable circuits, or specific tools to ensure that this is done routinely. Based on our observations, we have devised a series of specific proposals to implement a patient-centered approach. With these interventions we aim to (a) directly ameliorate TB patients well-being in any diagnostic/healthcare management center and (b) at more general level, to increase TB detection and treatment adherence. Conclusions: The patient-centered TB management recommended by the WHO might be essential for patients' well-being, but there is a lack of circuits or working protocols that ensure its implementation in a regulated manner. In the present manuscript we explain the various concrete measures that we propose in our region and which could be put into practice in other cities or geographic regions with similar epidemiological characteristics.

SUBMITTER: Pujol-Cruells A

PROVIDER: S-EPMC6901950 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Specific Interventions for Implementing a Patient-Centered Approach to TB Care in Low-Incidence Cities.

Pujol-Cruells Adrià A Vilaplana Cristina C

Frontiers in medicine 20191126

<b>Background:</b> According to the latest Guidelines from the World Health Organization, there is an increasing need for patient-centered tuberculosis disease management given the socio-economic factors influencing the tuberculosis epidemic. In the present study, we aimed to study TB in Barcelona city from an anthropological point of view and to devise a series of specific proposals to implement a patient-centered approach in our setting. <b>Methods:</b> We carried out a qualitative study using ...[more]

PMID: 31850353

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Project description:BackgroundExperts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care ("SPARC implementation intervention" hereafter). The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics.Methods/designThe SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015-July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies.DiscussionThe SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care-alcohol screening and brief intervention-as well as diagnosis and treatment of AUDs.Trial registrationThe trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777 .

Project description:Background/AimsPatient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (2001) promulgates as essential to improving healthcare delivery. The National Cancer Institute?s Strategic Plan for Leading the Nation (2008) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders have different conceptualizations and assumptions about how to measure it. The purpose of our study was to develop a set of self-administered patient survey items for comprehensive PCC assessment.MethodsOur approach was grounded in the PCC conceptual framework, as presented in the NCI monograph, Patient-Centered Communication in Cancer Care (2007), which defines six functions of PCC:First, we developed a comprehensive inventory of measurement domains and subdomains, aligned with the PCC functions, by reviewing relevant literature, consulting experts, and conducting a small qualitative study involving patient interviews. Next, we inventoried over 100 survey and other measurement instruments, identifying over 1,300 possible items. We evaluated items using a systematic question appraisal system, adapted existing measures as appropriate, and developed new questions to fill identified gaps. Finally, we tested more than 200 survey questions with cancer patients (n=46) using cognitive interviews.ResultsOverall, the findings from the cognitive interviews suggest that the survey questions function well. Patients were generally able to understand the questions and apply them to their own experiences. Many participants reported that the questions reflected important aspects of their interaction with providers.ConclusionsThe draft PCC survey items can now be used for population surveillance, quality assessment, and intervention research in the context of cancer care. Although the survey items focus on PCC with respect to cancer care, many are relevant to all patients as patient-centered care is a goal for health care generally. We discuss challenges of PCC assessment, including measuring communication experiences across different care settings, types of clinicians, and stages in the cancer care continuum. Measuring PCC longitudinally over the course of care and balancing parsimony and comprehensiveness are important considerations.

Project description:Although launched in 2015, little is known about the accuracy of QuantiFERON-TB Gold-Plus (QFT-Plus) for diagnosis of latent M. tuberculosis infection (LTBI). Unlike its predecessor, QFT-Plus utilizes two antigen tubes to elicit an immune response from CD4+ and CD8+ T lymphocytes. We conducted a cross-sectional study in low-risk health care workers (HCWs) at a single U.S. center to compare QFT-Plus to QuantiFERON-TB Gold in-tube (QFT). A total of 989 HCWs were tested with both QFT and QFT-Plus. Risk factors for LTBI were obtained from a questionnaire. QFT-Plus was considered positive if either antigen tube 1 (TB1) or TB2 tested positive, per the manufacturer's recommendations, or if both TB1 and TB2 tested positive, using a conservative definition. Results were compared using Cohen's kappa and linear regression, respectively. Agreement of QFT with QFT-Plus was high, at 95.6% (95% confidence interval [CI], 94.3 to 96.9; kappa, 0.57). The majority of discordant results between QFT and QFT-Plus TB1 (84.8%) and QFT and QFT-Plus TB2 (88.6%) fell within the range of 0.2 to 0.7 IU/ml. The positivity rate in 626 HCWs with no identifiable risk factors and no self-reported history of positive LTBI tests was 2.1% (CI, 1.0 to 3.2) and 3.0% (CI, 1.7 to 4.3) with QFT and QFT-Plus, respectively. A conservative definition of a QFT-Plus-positive result yielded a positivity rate of 1.0% (CI, 0.2 to 1.7; P value of 0.0002 versus QFT-Plus and 0.07 versus QFT). On follow-up testing, of 11 HCWs with discordant QFT-Plus results, 90.9% (10/11) had a negative QFT result. The QFT-Plus assay showed a high degree of agreement with QFT in U.S. HCWs. A conservative interpretation of QFT-Plus eliminated nearly all nonreproducible positive results in low-risk HCWs. Larger studies are needed to validate the latter finding and to more clearly define conditions under which a conservative interpretation can be used to minimize nonreproducible positive results in low-risk populations.

Project description:IntroductionEngaging patients and family members as partners in research increases the relevance of study results and enhances patient-centered care; how to best engage patients and families in research is unknown.MethodsWe tested a novel research approach that engages and trains patients and family members as researchers to see if we could understand and describe the experiences of patients admitted to the intensive care unit (ICU) and their families. Former patients and family members conducted focus groups and interviews with patients (n = 11) and families of surviving (n = 14) and deceased (n = 7) patients from 13 ICUs in Alberta Canada, and analyzed data using conventional content analysis. Separate blinded qualitative researchers conducted an independent analysis.ResultsParticipants described three phases in the patient/family "ICU journey"; admission to ICU, daily care in ICU, and post-ICU experience. Admission to ICU was characterized by family shock and disorientation with families needing the presence and support of a provider. Participants described five important elements of daily care: honoring the patient's voice, the need to know, decision-making, medical care, and culture in ICU. The post-ICU experience was characterized by the challenges of the transition from ICU to a hospital ward and long-term effects of critical illness. These "ICU journey" experiences were described as integral to appropriate interactions with the care team and comfort and trust in the ICU, which were perceived as essential for a community of caring. Participants provided suggestions for improvement: 1) provide a dedicated family navigator, 2) increase provider awareness of the fragility of family trust, 3) improve provider communication skills, 4) improve the transition from ICU to hospital ward, and 5) inform patients about the long-term effects of critical illness. Analyses by independent qualitative researchers identified similar themes.ConclusionsPatient and family member-led research is feasible and can identify opportunities for improving care.

Project description:BACKGROUND:Cardiovascular disease (CVD) is the leading cause of death in the US and incurs high health care costs. While many initiatives promote the implementation of ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) measures, most primary care practices (PCPs) lack quality improvement (QI) support and resources to achieve meaningful targets. The Healthy Hearts for Oklahoma (H2O) Study proposes to build a QI infrastructure by (1) constructing a sustainable Oklahoma Primary Healthcare Improvement Collaborative (OPHIC) to support dissemination and implementation (D&I) of QI methods; (2) providing QI support in PCPs to better manage patients at risk for CVD events. Parallel to infrastructure building, H2O aims to conduct a comprehensive evaluation of the QI support D&I in primary care and assess the relationship between QI support uptake and changes in ABCS measures. METHODS:H2O has partnered with public health agencies and communities to build OPHIC and facilitate QI. H2O has 263 small primary care practices across Oklahoma that receive the bundled QI intervention to improve ABCS performance. A stepped-wedge designed is used to evaluate D&I of QI support. Changes in ABCS measures will be estimated as a function of various components of the QI support and capacity and readiness of PCPs to change. Notes from academic detailing and practice facilitation sessions will be analyzed to help interpret findings on ABCS performance. DISCUSSION:H2O program is designed to improve cardiovascular health and outcomes for more than 1.25 million Oklahomans. The infrastructure established as a result of this funding will help reach medically underserved Oklahomans, particularly among rural and tribal populations. Lessons learned from this project will guide future strategies for D&I of evidence-based practices in PCPs. Trained practice facilitators will continue to serve as critical resource to assists small, rural PCPs in adapting to the ever-changing health environment and continue to deliver quality care to their communities.

Dataset Information

Specific Interventions for Implementing a Patient-Centered Approach to TB Care in Low-Incidence Cities.

Publications

Specific Interventions for Implementing a Patient-Centered Approach to TB Care in Low-Incidence Cities.

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