Showing papers by "Lee A. Green published in 2016"

Effect of care management program structure on implementation: a normalization process theory analysis

Abstract: Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice. Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework. Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively. Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.

Building research & scholarship capacity in departments of family medicine: a new joint adfm-napcrg initiative

Abstract: Transformative growth in the capacity of family medicine and primary care research and scholarship in the United States and Canada is crucial.1 Far greater capacity is needed to: generate the necessary knowledge; design, evaluate, and disseminate the innovations; and inform the implementation of sustainable systems change that will move us closer to better health, better health care, and affordable cost (The Triple Aim).1 Family medicine research encompasses clinical, health services, prevention, population health, health policy, community-based participatory research, educational innovation and evaluation, synthesis and dissemination of evidence, and the science of implementation. Each of these domains is necessary for the efficient and effective translation of biological discovery and new technology development into ethically sound practice and policy.

A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes.

Abstract: The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM). We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases. We used a quasi-experimental two-group pre-post design using the difference-in-differences method. Commercially insured patients, with any of the five chronic diseases—congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study. Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up. A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: −2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: −2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %). Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients’ clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation.

Training Change Agents in CTA to Bring Health Care Transformation to Scale The Case of Primary Care Practice Facilitators

Abstract: Primary care medical practice is in a period of transformational change. Practices have limited capacity to cope with this transformation. Thousands of practices require support, and any interventi...

Primary Care Pathway for Childhood Asthma: Protocol for a Randomized Cluster-Controlled Trial

Abstract: Background: Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families. Objective: The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient’s electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care. Methods: The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta.

Simulation of ICD-9 to ICD-10-CM Transition for Family Medicine: Simple or Convoluted?

Abstract: Objective: The objective of this study was to examine the impact of the transition from International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), to Interactional Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM), on family medicine and to identify areas where additional training might be required. Methods: Family medicine ICD-9-CM codes were obtained from an Illinois Medicaid data set (113,000 patient visits and $5.5 million in claims). Using the science of networks, we evaluated each ICD-9-CM code used by family medicine physicians to determine whether the transition was simple or convoluted. A simple transition is defined as 1 ICD-9-CM code mapping to 1 ICD-10-CM code, or 1 ICD-9-CM code mapping to multiple ICD-10-CM codes. A convoluted transition is where the transitions between coding systems is nonreciprocal and complex, with multiple codes for which definitions become intertwined. Three family medicine physicians evaluated the most frequently encountered complex mappings for clinical accuracy. Results: Of the 1635 diagnosis codes used by family medicine physicians, 70% of the codes were categorized as simple, 27% of codes were convoluted, and 3% had no mapping. For the visits, 75%, 24%, and 1% corresponded with simple, convoluted, and no mapping, respectively. Payment for submitted claims was similarly aligned. Of the frequently encountered convoluted codes, 3 diagnosis codes were clinically incorrect, but they represent only Conclusions: The transition to ICD-10-CM is simple for 70% or more of diagnosis codes, visits, and reimbursement for a family medicine physician. However, some frequently used codes for disease management are convoluted and incorrect, and for which additional resources need to be invested to ensure a successful transition to ICD-10-CM.

Effect of medication timing on anticoagulation stability in users of warfarin (the INRange RCT): study protocol for a randomized controlled trial.

Abstract: Warfarin is an oral anticoagulant medication that disrupts the liver’s production of clotting factors. While this medication is highly effective for the prevention of thromboembolic events, it also has a narrow therapeutic range and a vulnerability to interactions with other drugs and vitamin K-containing foods. Warfarin is commonly ingested at dinnertime, the same time of day that dietary vitamin K consumption (found largely in green leafy vegetables) is most variable. While the long half-life of warfarin might make this irrelevant, the ultra short half-life of vitamin K and the possibility of a hepatic first-pass effect for warfarin make it worth evaluating whether morning ingestion of warfarin, when vitamin K levels are consistently low, leads to greater stability of its anticoagulant effect. An examination of the timing of administration on the effectiveness of warfarin has never before been conducted. This is a 7-month Prospective Randomized Open Blinded End-point (PROBE) study in which established evening warfarin users (primary care managed Canadian outpatients in the provinces of British Columbia and Alberta) will be randomized to either switch to morning ingestion of warfarin (the intervention) or to continue with evening use (the control). The primary outcome is the percent change in the proportion of time spent outside the therapeutic range of the international normalized ratio (INR) blood test. Secondary outcomes include change in proportion of time spent within the therapeutic INR range (TTR), percentage of patients with TTR >75 %, percentage of patients with TTR <60 %, and major warfarin-related cardiovascular events (including all-cause mortality, hospitalization for stroke, hospitalization for GI bleeding, and deep venous thrombosis/pulmonary embolism). We will also compare whether day-to-day variability in the consumption of high vitamin K-containing foods at baseline affects the baseline TTR in this cohort of evening warfarin users. This study addresses whether the timing of warfarin ingestion influences the stability of its anticoagulant effect. Should morning ingestion prove superior, the safety and effectiveness of this medication, and hence the prevention of stroke, pulmonary embolus, and major hemorrhage, could potentially be improved with no added cost or inconvenience to the patient. ClinicalTrials.gov: NCT02376803 . Registered on 25 February 2015.

The building research capacity (brc) initiative: to be launched at the 2016 annual napcrg meeting

Abstract: ADFM and NAPCRG approved the recommendations of a Joint ADFM-NAPCRG Task Force in November 2015. That Task Force recommended creation of a steering committee to implement a bi-national research capacity building initiative for Departments of Family Medicine (DFM) in the US and Canada.[1][1] The

Incentive payments: the correct lesson.

Abstract: Lavergne and colleagues found that incentive payments to primary care physicians for the care of patients with complex disease had no impact on health care outcomes.[1][1] That’s an important finding, but the wrong lesson is easily drawn from it. The correct lesson is not that incentives do not