"Increasing Warm Handoffs: Optimizing Community Based Referrals in Primary Care Using QI Methodology".
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SUBMITTER: Sanderson D
PROVIDER: S-EPMC8202298 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:The "shared-care model" for patients with cancer involves care coordination between primary care providers (PCPs) and oncologists, with the goal of optimizing survivorship care. However, a high proportion of adolescent and young adult (AYA) cancer survivors do not have a PCP. Study objectives were to increase the percentage of AYAs with a PCP documented in the electronic medical record (EMR) via the use of a best practice advisory (BPA) or "stopgap" intervention; to increase communication between providers by the number of routed clinic notes; and to assess oncology providers' attitudes/beliefs about the model and intervention. METHODS:Data were collected for the 6 months before implementation of the BPA to determine the percentage of AYAs with a PCP and the number of notes routed to providers (time point 1 [T1]). The same data were collected at time point 2 (T2) after the BPA had been implemented for 6 months. Oncology providers participated in an education video module and an online survey at T1 and a survey at T2. RESULTS:At T1, 47.1% of 756 AYAs had a documented PCP in the EMR. At T2, the percentage increased to 55.1% (P<.002). The number of routed notes did not change significantly from T1 to T2. Providers that completed the intervention survey agreed/strongly agreed that the shared-care model is a desirable model of care (T1 = 86%; T2 = 93%) and that a BPA is useful for facilitating PCP referrals (T1 = 76%; T2 = 39%). CONCLUSIONS:This BPA is feasible for increasing the percentage of AYAs with a PCP documented in the EMR and could potentially lead to increased PCP referral and communication among providers for the benefit of long-term survivorship care. Providers generally agree with the shared-care model; however, the BPA implementation requires modification.
| S-EPMC5537736 | biostudies-literature
Project description:BackgroundPrimary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice.MethodsHealthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients.ResultsReferrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists' and ophthalmologists' referral rate did not change.ConclusionsThe introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.
| S-EPMC2924333 | biostudies-literature
Project description:IntroductionThe Diabetes Prevention Program, an intensive lifestyle change program, effectively reduces the risk of progression from prediabetes to type 2 diabetes but is underutilized. An implementation study using formative research was undertaken to increase Diabetes Prevention Program referrals at a primary care clinic.Study designA pragmatic, cluster randomized, mixed-methods study.Setting/particpantsClusters were teams of primary care clinicians from 2 primary care clinics. The 3 intervention clusters had 8-11 clinicians, and the 3 control clusters had 7-20 clinicians.InterventionImplementation activities occurred from December 2017 to February 2019. The activities included targeted clinician education, a prediabetes clinician champion, and a custom electronic health record report identifying patients with prediabetes.Main outcome measuresThe primary outcome was referral of patients with prediabetes to the institutional Diabetes Prevention Program. Study data, including patient demographic and clinical variables, came from electronic health record. Interviews with clinicians evaluated the implementation strategies. Generalized estimating equation analyses that accounted for multiple levels of correlation and interview content analysis occurred in 2019.ResultsStudy clinicians cared for 2,992 patients with a prediabetes diagnosis or HbA1c indicative of prediabetes (5.7%-6.4%). Clinicians in the intervention clusters referred 6.9% (87 of 1,262) of patients with prediabetes to the Diabetes Prevention Program and those in the control clusters referred 1.5% (26 of 1,730). When adjusted for patient age, sex, race, HbA1c value, HbA1c test location, and insurance type, intervention clinicians had 3.85 (95% CI=0.40, 36.78) greater odds of referring a patient with prediabetes to the Diabetes Prevention Program. The 11 interviewed intervention clinicians had mixed opinions about the utility of the interventions, reporting the prediabetes clinic champion (n=7, 64%) and educational presentations (n=6, 55%) as most helpful.ConclusionsIntervention clinicians were more likely to make Diabetes Prevention Program referrals; however, the study lacked power to achieve statistical significance. Clinician interviews suggested that intervention components that triggered Diabetes Prevention Program referrals varied among clinicians.
| S-EPMC7346283 | biostudies-literature
Project description:ImportanceDisparities in quality of care according to patient race and socioeconomic status persist in the US. Differential referral patterns to specialist physicians might be associated with observed disparities.ObjectiveTo examine whether differences exist between Black and White Medicare beneficiaries in the observed patterns of patient sharing between primary care physicians (PCPs) and physicians in the 6 specialties to which patients were most frequently referred.Design, setting, and participantsThis cross-sectional observational study of Black and White Medicare beneficiaries used claims data from 2009 to 2010 on 100% of traditional Medicare beneficiaries who were seen by PCPs and selected high-volume specialists in 12 health care markets with at least 10% of the population being Black. Statistical analyses were conducted from December 20, 2017, to September 30, 2020.ExposuresDifferences in patterns of patient sharing among Black and White patients.Main outcomes and measuresPrimary care physician and specialist degree (the number of other PCPs or specialists to whom each physician is connected) and strength (the number of shared patients per connection, overall, for Black patients and White patients and after equalizing the numbers of Black and White patients per PCP), as well as distance between PCP and patient and specialist zip code centroids.ResultsThe 12 selected markets ranged in size from Manhattan, New York (187 054 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 9794 total physicians), to Tallahassee, Florida (44 644 Black or White beneficiaries seen by at least 2 physicians within an episode of care; 847 total physicians). The percentage of Black beneficiaries ranged from 11.5% (Huntsville, Alabama) to 46.8% (Chicago, Illinois). The mean PCP-specialist degree (number of specialists with whom a PCP shares patients) was lower for Black patients than for White patients. For instance, the mean PCP-cardiologist degree across all markets for White patients was 17.5 compared with 8.8 for Black patients. After sampling White patients to equalize the numbers of patients seen, the degree differences narrowed but were still not equivalent in many markets (eg, for all specialties in Baton Rouge, Louisiana: 4.5 for Black patients vs 5.7 for White patients). Specialist networks among White patients were much larger than those constructed based just on Black patients (eg, for cardiology across all markets: 135 for Black patients vs 330 for White patients), even after equalizing the numbers of patients seen per PCP (123 for Black patients vs 211 for White patients). The overall test for differences in referral patterns was statistically significant for all 6 specialties examined in 7 of the 12 markets and in 5 specialties for another 3.Conclusions and relevanceThis study suggests that differences exist in specialist referral patterns by race among Medicare beneficiaries. This is an observational study, and thus some differences might have resulted from patient-initiated visits to specialists.
| S-EPMC7835717 | biostudies-literature
Project description:Little is known about referrals from primary care providers (PCPs) for suspected hematologic malignancies, including their clinical triggers and frequency. A random sample of 190 Massachusetts PCPs were presented with a vignette concerning a patient with a new finding of moderate anemia, asked how they would respond, and then asked what they would do if the patient returned with persistent anemia plus one additional sign or symptom. We also asked about referral behaviors for suspected hematologic malignancies during the prior year. A total of 134 (70.5%) PCPs responded. At first anemia presentation,only 3.8% reported referring to hematology. The development of a second sign or symptom yielded higher referral rates: pancytopenia 588.7%, leukopenia 5 63.9%, thrombocytopenia 5 63.9%, lymphadenopathy 5 42.9%, leukocytosis 5 37.6%, night sweats 5 25.6%, and weight loss 5 23.3%. The median yearly number (interquartile range) of patients PCPs reported suspecting of having hematologic malignancy was 5 (3, 10), and the median formally referred was 5 (3, 10). We conclude that anemia plus signs and symptoms suggestive of myelodysplasia or leukemia (compared with those suggestive of lymphoma) are more likely to prompt hematology referral. In addition, given their rarity,the numbe
| S-EPMC3358503 | biostudies-literature
Project description:To examine referral by primary care providers (PCPs) of preschool children with obesity (?95th percentile for body mass index [BMI]) to a weight management intervention when offered through a randomized clinical trial (RCT), and identify reasons for not referring children.In phase I, 3 experts in obesity, psychology, and nutrition completed an open card sort and classified PCPs' reasons for declining referral into groups based on similarity of reasons. Categories were then defined and labeled. In phase II, 2 independent sorters placed each decline into 1 of the categories defined in phase I.PCPs referred 78% of eligible children to the RCT. Compared with children declined for referral, referred children had a significantly higher weight (48.4 lb vs 46.1?lb; P?<?.001) and BMI percentile (97.6 vs 97.0; P?<?.001). Eleven categories for decline were identified in phase I. In phase II, excellent reliability was obtained between each independent sorter and the phase I categories, and also between the 2 independent sorters (? values, 0.72-1.0). The most common reason for declining was "family not a good fit" (23.6%), followed by "doesn't believe weight is a problem" (13.9%), "family would not be interested" (12%), and "doesn't believe measurement is accurate" (11.5%). Appropriately, exclusionary criteria of the RCT was a reason as well (11.8%).The availability of weight management for preschoolers through RCTs appeared to overcome barriers of resources, time, and credible treatment cited in previous studies. However, concerns about the family's response or interest in a weight management program remained barriers, as did PCPs' perceptions about obesity in young children.ClinicalTrials.gov:NCT01546727.
| S-EPMC5037027 | biostudies-literature
Project description:BackgroundTobacco smoke exposure (TSE) and inappropriate sleep position/environments contribute to preventable infant deaths. The objective of our quality improvement (QI) program was to increase primary care provider (PCP) screening and counseling for TSE and safe sleep risks at well-child visits (WCVs) and to assess caregiver behavior changes at subsequent visits.MethodsPediatric practices, recruited from the Ohio Chapter, American Academy of Pediatrics' database, self-selected to participate in this TSE and safe sleep PCP QI program. At every WCV over a 10-month period, caregivers with children <?1?year old were to be screened and counseled by providers. Caregiver demographics, TSE, and safe sleep practices were assessed. Individual PCP results were paired with subsequent family screening tools at follow up visits to determine changes in TSE and safe sleep practices. Differences in frequencies were determined and paired t-tests were used to compare means.ResultsFourteen practices (60 providers) participated; 7289 screens were completed: 3972 (54.5%) initial screens and 1769 (24.3%) subsequent WCV screens. Caregivers on the initial screen were primarily white (61.7%), mothers (86.0%) with public insurance (41.7%). Within the first month after QI program initiation, PCPs TSE screening was during 80% of WCVs, which increased to >?90% by end of the QI program. A total of 637 /3953 (16.1%) screened positive for home TSE on the initial visit: 320/3953 (8.1%) exposed by at least the primary caregivers, and 317/3953 (8.0%) exposed by a home adult smoker (not the identified caregiver). Of caregivers receiving smoking counseling with subsequent follow-up WCV (n?=?100), the mean number of cigarettes smoked daily decreased significantly from 10.6 to 4.6 (p?=?0.03). Thirty-four percent of caregivers (34/100) reported they quit smoking at their second visit. A total of 1072 (27%) infants screened at risk for inappropriate sleep position or environment at their initial visit. Of these at-risk infants whose caregivers received safe sleep counseling, 49.1% practiced safer sleep behaviors at follow-up.ConclusionsPCPs participating in a QI program increased screening at WCVs for infant mortality risks. After counseling and providing resources about TSE and safe sleep, many caregivers reported practicing safer behaviors at their next WCV.
| S-EPMC7291417 | biostudies-literature
Project description:This project aimed to increase same-day emergency care (SDEC)-suitable activity within an existing ambulatory medical unit, in line with the recommendations set out in the NHS Long Term Plan. Prior to the project, much of the unit's activity was non-urgent and focused on supporting early discharges. Scoping exercises were undertaken to better understand current activity and identify interventions to increasing same-day referrals from within the urgent and emergency care system. Quality improvement methodology was then used to implement and study a variety of interventions, including but not limited to the development of new condition-based referral pathways. Retrospective review of SDEC activity demonstrated a threefold increase.
| S-EPMC11363703 | biostudies-literature
Project description:IntroductionReferrals to evidence-based weight management in the community-commercial sector are aligned with clinical recommendations but underutilized.MethodsThis qualitative study explored patients' perceptions and expectations about obesity treatment in primary care and referral to community-commercial sector programs. Individual semi-structured interviews were conducted with a sample of US persons with obesity via telephone. Audiotape transcripts, interviewer notes, and independent review of data by two investigators allowed for data and investigator triangulation. Transcripts were analyzed using thematic analysis.ResultsData saturation was reached with 30 participants who had a mean age of 41.6 years (SD 9.4), 37% male, 20% Black/African American and 17% Hispanic, 57% college educated, and 50% were employed full-time. Three primary themes emerged: (1) frustration with weight management in primary care; (2) patients expect providers to be better informed of and offer treatment options; and (3) opportunities and challenges with referrals to community-commercial programs.DiscussionPatients expect that providers offer personalized treatment options and referrals to effective community-commercial programs are an acceptable option. If patient-level data are shared between clinical and community entities to facilitate referrals, then privacy and security issues need attention. Future research is needed to determine feasibility of implementing clinical to community-commercial referrals for obesity treatment in the United States.
| S-EPMC10435859 | biostudies-literature
Project description:Operating room to intensive care unit handoffs are high-risk events for critically ill patients. Studies in selected patient populations show that standardizing operating room to intensive care unit handoffs improves information exchange and decreases errors. To adapt these findings to mixed surgical populations, we propose to study the implementation of a standardized operating room to intensive care unit handoff process in two intensive care units currently without an existing standard process.The Handoffs and Transitions in Critical Care (HATRICC) study is a hybrid effectiveness- implementation trial of operating room to intensive care unit handoffs. We will use mixed methods to conduct a needs assessment of the current handoff process, adapt published handoff processes, and implement a new standardized handoff process in two academic intensive care units. Needs assessment: We will use non-participant observation to observe the current handoff process. Focus groups, interviews, and surveys of clinicians will elicit participants' impressions about the current process. Adaptation and implementation: We will adapt published standardized handoff processes using the needs assessment findings. We will use small group simulation to test the new process' feasibility. After simulation, we will incorporate the new handoff process into the clinical work of all providers in the study units.Using the same methods employed in the needs assessment phase, we will evaluate use of the new handoff process.The primary effectiveness outcome is the number of information omissions per handoff episode as compared to the pre-intervention period. Additional intervention outcomes include patient intensive care unit length of stay and intensive care unit mortality. The primary implementation outcome is acceptability of the new process. Additional implementation outcomes include feasibility, fidelity and sustainability.The HATRICC study will examine the effectiveness and implementation of a standardized operating room to intensive care unit handoff process. Findings from this study have the potential to improve healthcare communication and outcomes for critically ill patients.ClinicalTrials.gov identifier: NCT02267174. Date of registration October 16, 2014.
| S-EPMC4255652 | biostudies-literature