This document summarizes a systematic review that identified key challenges and barriers to implementing the patient-centered medical home (PCMH) model based on 28 studies from the United States. The review found six main challenges: 1) difficulties transforming practice operations and managing change, 2) implementing functional electronic health records, 3) inadequate funding and payment models, 4) insufficient practice resources and infrastructure, 5) variations in PCMH standards and accreditation, and 6) limitations in performance measures. The review concludes that understanding these challenges is important for Australian health reforms considering adopting PCMH elements.
Partial and Incremental PCMH Practice Transformation: Implications for Qualit...Paul Grundy
Experience of BCBS Michigan in Building medical homes
Based on the observed relationships for partial implementation,full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population.
Conclusions. Estimated effects of the PCMH model on quality and cost of care
appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...Marion Sills
Kwan BM, Sills MR, Graham D, Hamer MK, Fairclough DL, Hammermeister KE, Kaiser A, Diaz-Perez MJ, Schilling LM. Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Practice-Based Research Network. JABFM. In Press.
Partial and Incremental PCMH Practice Transformation: Implications for Qualit...Paul Grundy
Experience of BCBS Michigan in Building medical homes
Based on the observed relationships for partial implementation,full implementation of the PCMH model is associated with a 3.5 percent higher quality composite score, a 5.1 percent higher preventive composite score, and $26.37 lower per member per month medical costs for adults. Full PCMH implementation is also associated with a 12.2 percent higher preventive composite score, but no reductions in costs for pediatric populations. Incremental improvements in PCMH model implementation yielded similar positive effects on quality of care for both adult and pediatric populations but were not associated with cost savings for either population.
Conclusions. Estimated effects of the PCMH model on quality and cost of care
appear to improve with the degree of PCMH implementation achieved and with incremental improvements in implementation.
Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Pra...Marion Sills
Kwan BM, Sills MR, Graham D, Hamer MK, Fairclough DL, Hammermeister KE, Kaiser A, Diaz-Perez MJ, Schilling LM. Stakeholder Engagement in a Patient-Reported Outcomes Implementation by a Practice-Based Research Network. JABFM. In Press.
Predicting volume of distribution for drug compounds using decision treesNithyakalyani Chinnaiah
The project is about improving the prediction accuracy of numerical value of volume of
distribution (VD), which is a proportionality constant for drug compounds. While there have been many approaches using regression with decision trees to predict VD, very few research studies have been carried out using classification scheme. This project proposes a method where the two approaches are combined with the addition of a classification confidence measure. The two stage classification-regression approach is studied with six different data divisions. In the proposed approach, a test drug’s class is predicted using molecular structures as attributes and if the prediction confidence is higher than a predetermined threshold, the log VD value is obtained using regression decision tree built for the particular class. If the classification prediction is not high, then the approach resorts to standard regression to obtain log VD value. This two stage approach seems to be promising as the cross validated performances are improved as compared to standard regression approach for two of the studied data divisions (one third and one fifth divisions) that gave geometric mean fold errors (GMFE) of 2.1502 and 2.2013 as compared to the standard regression GMFE of 2.2373 and 2.2356, respectively.
A personalized training workshop for the PRM Department Staff at KSUMC at large. The specific target audience is the CPG working groups and new committee members.
An introduction on Evidence-Based Clinical Practice Guidelines in Health Care Organizations
Brief on Alexandria Center for EBCPGs in Alexandria University Hospitals, Egypt
By Dr. Yasser Sami Abdel Dayem Amer, MBBCh, MS 2013
Special Thanks to
Prof Dr Mahmoud Elzalabany
Prof Dr Tarek Omar
Prof Dr Nabil Dowidar
Prof Dr Afaf Gaber
Health outcomes research is seen as a cost-effective investment in measuring and defining value of new innovations in health care. We provide an overview of field and its applications
The Adapted ADAPTE approach to CPG adaptation proposed by the Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Egypt.
An oral presentation conducted by Prof. Tarek Omar during the national initiative of the Pediatrics Department, Armed Forces College of Medicine, themed; 'Towards National Guidelines' that was launched in 2018 and started by Pediatrics CPGs
Health Outcomes, Quality, and Cost: Opportunities for Pediatric EndocrinologyJoyce Lee
My talk for the Paul Kaplowitz Endowed Lectureship for contributions to quality and cost-effective care in Pediatric Endocrinology at the Pediatric Endocrine Society Meeting 2016. Thank you so much Dr. Kaplowitz! And a hat tip to Lawson Wilkins, who developed learning health systems ages ago.
Overview of the progress of the KSUMC Clinical Practice Guidelines Adaptation and Implementation Program in the Department of Pediatrics which is the most active department in the program
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
Predicting volume of distribution for drug compounds using decision treesNithyakalyani Chinnaiah
The project is about improving the prediction accuracy of numerical value of volume of
distribution (VD), which is a proportionality constant for drug compounds. While there have been many approaches using regression with decision trees to predict VD, very few research studies have been carried out using classification scheme. This project proposes a method where the two approaches are combined with the addition of a classification confidence measure. The two stage classification-regression approach is studied with six different data divisions. In the proposed approach, a test drug’s class is predicted using molecular structures as attributes and if the prediction confidence is higher than a predetermined threshold, the log VD value is obtained using regression decision tree built for the particular class. If the classification prediction is not high, then the approach resorts to standard regression to obtain log VD value. This two stage approach seems to be promising as the cross validated performances are improved as compared to standard regression approach for two of the studied data divisions (one third and one fifth divisions) that gave geometric mean fold errors (GMFE) of 2.1502 and 2.2013 as compared to the standard regression GMFE of 2.2373 and 2.2356, respectively.
A personalized training workshop for the PRM Department Staff at KSUMC at large. The specific target audience is the CPG working groups and new committee members.
An introduction on Evidence-Based Clinical Practice Guidelines in Health Care Organizations
Brief on Alexandria Center for EBCPGs in Alexandria University Hospitals, Egypt
By Dr. Yasser Sami Abdel Dayem Amer, MBBCh, MS 2013
Special Thanks to
Prof Dr Mahmoud Elzalabany
Prof Dr Tarek Omar
Prof Dr Nabil Dowidar
Prof Dr Afaf Gaber
Health outcomes research is seen as a cost-effective investment in measuring and defining value of new innovations in health care. We provide an overview of field and its applications
The Adapted ADAPTE approach to CPG adaptation proposed by the Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Egypt.
An oral presentation conducted by Prof. Tarek Omar during the national initiative of the Pediatrics Department, Armed Forces College of Medicine, themed; 'Towards National Guidelines' that was launched in 2018 and started by Pediatrics CPGs
Health Outcomes, Quality, and Cost: Opportunities for Pediatric EndocrinologyJoyce Lee
My talk for the Paul Kaplowitz Endowed Lectureship for contributions to quality and cost-effective care in Pediatric Endocrinology at the Pediatric Endocrine Society Meeting 2016. Thank you so much Dr. Kaplowitz! And a hat tip to Lawson Wilkins, who developed learning health systems ages ago.
Overview of the progress of the KSUMC Clinical Practice Guidelines Adaptation and Implementation Program in the Department of Pediatrics which is the most active department in the program
National Conference on Health and Domestic Violence. Plenary talk Paul Grundy
explaining how the Patient Centered Medical Home (PCMH) platform for healthcare deliver is more likely to support domestic violence prevention and creat a safer environment than the FFS episode of care system we are in now. The medical Home is a home for the data where the all the data goes and is held accountable this idea was first articulated by Dr. Calvin C.J. Sia, a Honolulu-based pediatrician in 1967.
This concept of the medical home was integrated with Ed Wagners Chronic disease Model and Thomas Bodenheimer Kevin Grumbach advanced/proactive primary care at the request of the Patient Centered Primary care Collaborative into a set of principles Know as the Joint principles of the Patient centered medical home.
The patient-centered medical home (PCMH), is a team based health care delivery set of principles led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is "an approach to providing comprehensive primary care for children, youth and adults" The provision PCMH medical homes allow better access to health care, increase satisfaction with care, and improve health. Joint principles that define a PCMH have been established through the cohesive efforts of the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and American Osteopathic Association (AOA).[10] Care coordination is an essential component of the PCMH. Care coordination requires additional resources such as health information technology, and appropriately trained staff to provide coordinated care through team-based models. Additionally, payment models that compensate PCMHs for their effort devoted to care coordination activities and patient-centered care management that fall outside the face-to-face patient encounter may help encourage coordination.
Patient-centered medical homes (PCMHs) are intended to actively provide effective care by physician-led teams, Where patients take a leading role and responsibility. Objective: To determine whether the Walter Reed PCMH has reduced costs while at least maintaining if not improving access to and quality of care, and to determine
whether access, quality, and cost impacts differ by chronic condition status. Design, setting, and patients: This study
conducted a retrospective analysis using a patient-level utilization database to determine the impact of the Walter Reed PCMH on utilization and cost metrics, and a survey of enrollees in the Walter Reed PCMH to address access to care and quality of care. Outcome measures: Inpatient and outpatient utilization, per member per quarter costs, Healthcare Effectiveness Data and Information Set metrics, and composite measures for access, patient satisfaction, provider communication, and customer service are included. Results: Costs were 11% lower for those with chronic conditions compared to 7% lower for those without. Since treating patients with chronic conditions is 4 times more costly than treating patients without such conditions, the vast majority of dollar savings are attributable to chronic care.
The Patient-Centered Medical Home in the Transformation From Healthcare to He...Paul Grundy
Surgeon General of the Navy VADM Matthew L. Nathan, MC USN
Fortunately, we have a way to address this crisis—the
Patient-Centered Medical Home (PCMH) model launched at Naval Hospital Pensacola and Walter Reed National Military Medical Center, Bethesda, Maryland (formerly the National Naval Medical Center) in 2008. It is now being implemented throughout the Military Health System (MHS) and carries great promise. It provides the clinical framework we need to meet our strategic objectives in terms of quality of care, impact on costs, population health, and readiness. One of the most significant benefits of the team-based, collaborative approach is that it allows us to embed within a primary care environment the psychologists, nutritionists, tobacco cessation specialists, mind-body medicine therapists, and health educators our patients need in order to develop and maintain mindful, healthy behaviors—along with the “mental armor,” our active duty military personnel need to increase their operational effectiveness and their resiliency in bouncing back from stressful situations. As we move ahead with this more comprehensive approach to health, we can begin to better address so many of our patients for whom we can find no specific reason for pain and discomfort. The PCMH model also provides a positive impact on our costs. Early data reporting from the PCMH clinics at Bethesda show reduced visits to the emergency room, lowered pharmacy costs, and significant per beneficiary per year savings and improved Healthcare Effectiveness Data and Information Set metrics, access, and patient satisfaction and trust. These positive impacts on the bottom line can be applied directly to improved costs or toward the reallocation of resources from reimbursing those who are sick to the population health-based programs that can make and keep our patients healthy.More significant, however, the PCMH environment allows us to go beyond mere collaboration and to a much more proactive approach to managing our patient populations. It is within the context of the medical home that we can begin to surround our patients with the tools and resources they need to move them from health care to health.
Evidence-Based PracticeEvidence-based Practice Progra.docxelbanglis
Evidence-Based
Practice
Evidence-based Practice
Program
The Agency for Healthcare Research and
Quality (AHRQ), through its Evidence-
based Practice Centers (EPCs), sponsors
the development of evidence reports and
technology assessments to assist public-
and private-sector organizations in their
efforts to improve the quality of health
care in the United States. The reports
and assessments provide organizations
with comprehensive, science-based
information on common, costly
medical conditions and new health care
technologies. The EPCs systematically
review the relevant scientific literature
on topics assigned to them by AHRQ
and conduct additional analyses when
appropriate prior to developing their
reports and assessments.
AHRQ expects that the EPC evidence
reports and technology assessments will
inform individual health plans, providers,
and purchasers as well as the health care
system as a whole by providing important
information to help improve health care
quality.
The full report and this summary are
available at www.effectivehealthcare.
ahrq.gov/reports/final.cfm.
Background
The United States spends a greater proportion
of its gross domestic product on health care
than any other country in the world (17.6
percent in 2009),1 yet often fails to provide
high-quality and efficient health care.2-6 U.S.
health care has traditionally been based on a
solid foundation of primary care to meet the
majority of preventive, acute, and chronic
health care needs of its population; however,
the recent challenges facing health care in
the United States have been particularly
magnified within the primary care setting.
Access to primary care is limited in many
areas, particularly rural communities. Fewer
U.S. physicians are choosing primary care as
a profession, and satisfaction among primary
care physicians has waned amid the growing
demands of office-based practice.7 There has
been growing concern that current models
of primary care will not be sustainable for
meeting the broad health care needs of the
American population.
The patient-centered medical home (PCMH)
is a model of primary care transformation that
seeks to meet the variety of health care needs
of patients and to improve patient and staff
experiences, outcomes, safety, and system
efficiency.8-11 The term “medical home”
was first used by the American Academy of
Pediatrics in 1967 to describe the concept of a
single centralized source of care and medical
record for children with special health care
Evidence Report/Technology Assessment
Number 208
2. The Patient-Centered Medical Home
Closing the Quality Gap: Revisiting the State of the Science
Executive Summary
2
needs.12 The current concept of PCMH has been greatly
expanded and is based on 40 years of previous efforts to
redesign primary care to provide the highest quality of care
possible.13,14 The chronic care model,15,16 a conceptual
model for organizing chronic illness ...
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxspoonerneddy
Chapter 7. The Evidence for Evidence-Based Practice
Implementation
Marita G. Titler
Background
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma,
heart failure, and diabetes. However, these practices are not always implemented in care
delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused
on data analyses to identify patient safety issues and to demonstrate that a new practice will lead
to improved quality and patient safety.5 Much less research attention has been paid to how to
implement practices. Yet, only by putting into practice what is learned from research will care be
made safer.5 Implementing evidence-based safety practices are difficult and need strategies that
address the complexity of systems of care, individual practitioners, senior leadership, and—
ultimately—changing health care cultures to be evidence-based safety practice environments.5
Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–
9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated
by Nightingale,10 the nursing profession has more recently provided major leadership for
improving care through application of research findings in practice.11
Evidence-based practice (EBP) is the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care
decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials;
evidence from other scientific methods such as descriptive and qualitative research; as well as
use of information from case reports, scientific principles, and expert opinion. When enough
research evidence is available, the practice should be guided by research evidence in conjunction
with clinical expertise and patient values. In some cases, however, a sufficient research base may
not be available, and health care decisionmaking is derived principally from nonresearch
evidence sources such as expert opinion and scientific principles.16 As more research is done in a
specific area, the research evidence must be incorporated into the EBP.15
Models of Evidence-Based Practice
Multiple models of EBP are available and have been used in a variety of clinical settings.16–36
Although review of these models is beyond the scope of this chapter, common elements of these
models are selecting a practice topic (e.g., discharge instructions for individuals with heart
failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient
care and provider performance, and consideration of the context/setting in which the practice is
implemented.15, 17 The learning that occurs during the process of translating research into
practice is valuable information to capture and feed back into the process, so that.
Chapter 7. The Evidence for Evidence-Based Practice Implem.docxmccormicknadine86
Chapter 7. The Evidence for Evidence-Based Practice
Implementation
Marita G. Titler
Background
Overview of Evidence-Based Practice
Evidence-based health care practices are available for a number of conditions such as asthma,
heart failure, and diabetes. However, these practices are not always implemented in care
delivery, and variation in practices abound.1–4 Traditionally, patient safety research has focused
on data analyses to identify patient safety issues and to demonstrate that a new practice will lead
to improved quality and patient safety.5 Much less research attention has been paid to how to
implement practices. Yet, only by putting into practice what is learned from research will care be
made safer.5 Implementing evidence-based safety practices are difficult and need strategies that
address the complexity of systems of care, individual practitioners, senior leadership, and—
ultimately—changing health care cultures to be evidence-based safety practice environments.5
Nursing has a rich history of using research in practice, pioneered by Florence Nightingale.6–
9 Although during the early and mid-1900s, few nurses contributed to this foundation initiated
by Nightingale,10 the nursing profession has more recently provided major leadership for
improving care through application of research findings in practice.11
Evidence-based practice (EBP) is the conscientious and judicious use of current best
evidence in conjunction with clinical expertise and patient values to guide health care
decisions.12–15 Best evidence includes empirical evidence from randomized controlled trials;
evidence from other scientific methods such as descriptive and qualitative research; as well as
use of information from case reports, scientific principles, and expert opinion. When enough
research evidence is available, the practice should be guided by research evidence in conjunction
with clinical expertise and patient values. In some cases, however, a sufficient research base may
not be available, and health care decisionmaking is derived principally from nonresearch
evidence sources such as expert opinion and scientific principles.16 As more research is done in a
specific area, the research evidence must be incorporated into the EBP.15
Models of Evidence-Based Practice
Multiple models of EBP are available and have been used in a variety of clinical settings.16–36
Although review of these models is beyond the scope of this chapter, common elements of these
models are selecting a practice topic (e.g., discharge instructions for individuals with heart
failure), critique and syntheses of evidence, implementation, evaluation of the impact on patient
care and provider performance, and consideration of the context/setting in which the practice is
implemented.15, 17 The learning that occurs during the process of translating research into
practice is valuable information to capture and feed back into the process, so that ...
In 2006, the Commission on Higher Education (CHED)
released CHED Memorandum Order (CMO) no. 14 which changed the
duration of internship training program to six months as opposed to
the previous memorandum order, CMO no. 27 s. 1998 which required
a one-year internship schedule for Medical Laboratory Science (MLS)
students. Thirty-eight graduates of CMO No. 14 s. 2006 from Lyceum of
the Philippines University-Batangas and 13 chief medical technologists
(CMT) or senior medical laboratory staff from identified affiliate-
hospitals were surveyed about their perception on the attainment of the
objectives, as well as the strengths and weaknesses of the said program.
Results show that objectives were achieved even if the duration of the
training period was shortened. The graduate-respondents favored the 6-month internship training program while the CMT preferred the
one year timetable. This study can be used as a pilot study for other
higher education institutions implementing the same CMO and can
be used as a basis for a curricular reform by assessing the different
parameters that were identified in order to enhance further the six-
month internship training program in producing globally competitive
medical laboratory scientists.
ACT500 Research Evaluation TablesArticle 1 Measuring Perfo.docxbobbywlane695641
ACT500: Research Evaluation Tables
Article 1: Measuring Performance
Insert reference in APA formatting, 6th ed. 4th printing
Research Topic
The topic is a broad subject. The topic is not the problem to be solved; that comes later. Example: Balanced Scorecard
Problem or Opportunity
The problem is established with factual data and is found in the introductory portion of the research article or report.
Purpose for the Research
The purpose of the study defines what the researcher wants to find out and is found in the introductory section of the research article. Sometimes the purpose contains a research question/s.
Research Methods
A researcher makes a decision about the broad nature of a research approach: typically quantitative/confirmatory or qualitative/exploratory. Research design strategies are driven by the chosen research approach and the research purpose. Research design strategies include: types of data collected, how the data is collected, and what preparation of data is used, analytical techniques, and presentation of information.
Audience
The groups, associates, profession, and/or individuals that the researcher suggests might benefit from the findings of this study
Research Evaluation
Assess the study’s Research Methods and Analytic Techniques. Are the research methods and analytic techniques applicable to solving practical management questions? Why or why not? You must substantiate your position with credible resources and examples.
Discuss how your organization might or might not use the findings from these studies. Substantiate your opinion with concrete examples.
Article 2: Incremental Analysis
Insert reference in APA formatting, 6th ed. 4th printing
Research Topic
The topic is a broad subject. The topic is not the problem to be solved; that comes later. Example: Cost Behavior
Problem or Opportunity
The problem is established with factual data and is found in the introductory portion of the research article or report.
Purpose for the Research
The purpose of the study defines what the researcher wants to find out and is found in the introductory section of the research article. Sometimes the purpose contains a research question/s.
Research Methods
A researcher makes a decision about the broad nature of a research approach: typically quantitative/confirmatory or qualitative/exploratory. Research design strategies are driven by the chosen research approach and the research purpose. Research design strategies include: types of data collected, how the data is collected, and what preparation of data is used, analytical techniques, and presentation of information.
Audience
The groups, associates, profession, and/or individuals that the researcher suggests might benefit from the findings of this study
Research Evaluation
Assess the study’s Research Methods and Analytic Techniques. Are the methods and analytic techniques applicable to solving practical management questions? Why or why not? You must substantiate your position wit.
S Y S T E M A T I C R E V I E WAntibiotic Prescribing in L.docxanhlodge
S Y S T E M A T I C R E V I E W
Antibiotic Prescribing in Long-Term Care Facilities:
A Meta-synthesis of Qualitative Research
Aoife Fleming1 • Colin Bradley2 • Shane Cullinan1 • Stephen Byrne1
Published online: 2 April 2015
� The Author(s) 2015. This article is published with open access at Springerlink.com
Abstract
Objectives The objective of this review was to synthesize
the findings of qualitative studies investigating the factors
influencing antibiotic prescribing in long-term care facilities
(LTCFs). These findings will inform the development of fu-
ture antimicrobial stewardship strategies (AMS) in this setting.
Methods We searched Embase, PubMed, PsycInfo, So-
cial Science Citations Index and Google Scholar for all
qualitative studies investigating health care professionals’
views on antibiotic prescribing in LTCFs. The quality of
the papers was assessed using the Critical Appraisal Skills
Programme (CASP) assessment tool for qualitative re-
search. Thematic synthesis was used to integrate the
emergent themes into an overall analytical theme.
Results The synthesis of eight qualitative studies indi-
cated that health care professionals and administrators have
identified factors that influence antibiotic prescribing in
LTCFs. These factors include variations in knowledge and
practice among health care professionals, and the LTCF
context, which is unique given the complex patient
population and restricted access to doctors and diagnostic
tests. The social factors underpinning the interaction be-
tween nurses, residents’ families and doctors also influence
decision making around antibiotic prescribing. The study
also found that there is an acknowledged need for col-
laborative, evidence-based AMS specific to LTCFs, as
antibiotic prescribing is heavily influenced by factors
unique to this setting.
Conclusion This review highlighted the key contextual
challenges for AMS in LTCFs. The findings provide an in-
depth insight into the factors—such as the LTCF context,
social factors, variability in knowledge and prescribing
practices, and antimicrobial resistance—that impact on
antibiotic prescribing and AMS strategies. These factors
must be considered in order to ensure the feasibility and
applicability of future AMS interventions.
Key Points
The influences of the long-term care facility (LTCF)
context and social factors have an important impact
on antibiotic prescribing in this setting.
According to the findings of this review, future
antimicrobial stewardship strategies must emphasize
the importance of knowledge of guidelines and
antimicrobial resistance, and the strategies must be
specifically designed for implementation in the
LTCF setting.
1 Introduction
Recent studies evaluating the prescribing of antibiotics in
long-term care facilities (LTCFs) have found that antibiotic
prescribing is common, with reported annual prevalence
rates ranging from 47 to 79 % [1]. As many as 25–75 % of
El.
Four strategies to upgrade clinical trial quality in this computerized world ...Pubrica
• Biostatistics Services is important for collecting, reviewing, presenting, and interpreting data in clinical research.
• Applications of clinical biostatistics services are in different areas, such as epidemiology, clinical trials, population genetics, the biology of structures, and more.
Reference : https://pubrica.com/services/research-services/biostatistics-and-statistical-programming-services/
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College Writing II Synthesis Essay Assignment Summer Semester 2017.docxclarebernice
College Writing II Synthesis Essay Assignment Summer Semester 2017
Directions:
For this assignment you will be writing a synthesis essay. A synthesis is a combination of two or more summaries and sources. In a synthesis essay you will have three paragraphs, an introduction, a synthesis and a conclusion.
In the introduction you will give background information about your topic. You will also include a thesis statement at the end of the introduction paragraph. The thesis statement should describe the goal of your synthesis. (informative or argumentative)
The second paragraph is the synthesis. You will combine two summaries of two different articles on the same topic. You will follow all summary guidelines for these two paragraphs. The synthesis will most likely either argue or inform the reader about the topic.
The conclusion paragraph should summarize the points of your essay and restate the general ideas.
For this essay you will read two research articles on a similar topic to the previous critical review essay as you can use this research in your inquiry paper. You will summarize both articles in two paragraphs and combine the paragraphs for your synthesis. In the synthesis you must include the main ideas of the articles and the author, title, and general idea in the first sentences.
This essay will be three pages long and the first draft and peer review are due June 15. You must turn them in hardcopy in class so you can do a peer review.
Running head: THESIS DRAFT 1
THESIS DRAFT 3Thesis Draft
Katelyn B. Rhodes
D40375299
DeVry University
Point-of-Care Testing (PoCT) has dramatically taken over the field of clinical laboratory testing since it’s introduction approximately 45 years ago. The technologies utilized in PoCT have been refined to deliver accurate and expedient test results and will become even more sensitive and accurate in order to dominate the field of clinical laboratory testing. Furthermore, there will be a dramatic increase in the volume of clinical testing performed outside of the laboratory. New and emerging PoCT technologies utilize sophisticated molecular techniques such as polymerase chain reaction to aid in the treatment of major health problems worldwide, such as sexually transmitted infections (John & Price, 2014).
Historic Timeline
In the early-to-mid 1990’s, bench top analyzers entered the clinical laboratory scene. These analyzers were much smaller than the conventional analyzers being used, and utilized touch-screen PCs for ease of use. For this reason, they were able to be used closer to the patient’s bedside or outside of the laboratory environment. However, at this point in time, laboratory testing results were stored within the device and would have to then be sent to the main central laboratory for analysis.
Technology in the mid-to-late 1990’s permitted analyzers to be much smaller so that they may be easily carried to the patient’s location. Computers also became more ...
Meta-Analysis of population studies on the prevalence of chronic pain in UK –...Pubrica
Chronic pain, which includes illnesses like low back pain and osteoarthritis, was recently highlighted as one of the most common causes of disability worldwide by the Global Burden of disease studies in a meta-analysis study.
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A systematic review of the challenges to implementation of the patient-centred medical home: lessons for Australia
1. S69MJA 201 (3) · 4 August 2014
Building a culture of co-creation in research
Tina Janamian
PhD, MMedSc, BSc
Senior Program Manager1
Claire L Jackson
MBBS, MD, MPH
Professor in Primary Health
Care Research,2 and Director3
Nicola Glasson
Medical Student4
Caroline Nicholson
GradDipPhty, MBA, GAICD
Director,5 and Honorary
Fellow2
1 Centre of Research
Excellence in Primary
Health Care Microsystems,
University of Queensland,
Brisbane, QLD.
2 Discipline of General
Practice, University of
Queensland,
Brisbane, QLD.
3 Centres for Primary Care
Reform Research Excellence,
University of Queensland,
Brisbane, QLD.
4 Faculty of Medicine, James
Cook University,
Townsville, QLD.
5 Mater–UQ Centre for
Primary Healthcare
Innovation, Mater Health
Services, Brisbane, QLD.
t.janamian1@uq.edu.au
doi: 10.5694/mja14.00295
Abstract
Objective: To review the available literature to identify
the major challenges and barriers to implementation and
adoption of the patient-centred medical home (PCMH)
model, topical in current Australian primary care reforms.
Study design: Systematic review of peer-reviewed
literature.
Data sources: PubMed and Embase databases were
searched in December 2012 for studies published in English
between January 2007 and December 2012.
Study selection: Studies of any type were included if
they defined PCMH using the Patient-Centered Primary
Care Collaborative Joint Principles, and reported data on
challenges and barriers to implementation and adoption of
the PCMH model.
Data extraction: One researcher with content knowledge
in the area abstracted data relating to the review objective
and study design from eligible articles. A second researcher
reviewed the abstracted data alongside the original article
to check for accuracy and completeness.
Data synthesis: Thematic synthesis was used to in three
stages: free line-by-line coding of data; organisation of
“free codes” into related areas to construct “descriptive”
themes and develop “analytical” themes. The main barriers
identified related to: challenges with the transformation
process; difficulties associated with change management;
challenges in implementing and using an electronic health
record that administers principles of PCMH; challenges
with funding and appropriate payment models; insufficient
resources and infrastructure within practices; and
inadequate measures of performance.
Conclusion: This systematic review documents the key
challenges and barriers to implementing the PCMH model
in United States family practice. It provides valuable
evidence for Australian clinicians, policymakers, and
organisations approaching adoption of PCMH elements
within reform initiatives in this country.
A systematic review of the challenges to
implementation of the patient-centred
medical home: lessons for Australia
Online first 21/07/14
A
ustralia’s first National Primary Health Care
Strategy1 and resulting National Primary Health
Care Strategic Framework2 initiated growing inter-
est and development in our primary care sector, particularly
general practice. Clinicians, governments and organisations
are now actively searching for new approaches, models
of care and business levers to support the primary care
quality, efficiency and access gains sought. In December
2012, then Minister for Health Tanya Plibersek announced
a focus on the patient-centred medical home (PCMH)
as a model of interest.3 The Royal Australian College of
General Practitioners (RACGP) has also been a consistent
champion of the model, urging adoption of its elements as
part of current reforms and calling for the federal govern-
ment to fund and implement key elements in its 2013–14
Budget submission.4
The PCMH concept of care was introduced by the
American Academy of Pediatrics in 1967, and was adopt-
ed in 2002 by the family medicine specialty. Four major
primary care physician associations in the United States,
along with other stakeholders, formed the Patient-Centered
Primary Care Collaborative (PCPCC), and in 2007 endorsed
the Joint principles of the patient-centered medical home.5
These include: access to a personal physician; physician-
directed medical practice; whole-person orientation; care
coordination and/or integration; quality and safety bench-
marking through evidence-based medicine and clinical
decision support tools; enhanced care availability after
hours and via e-health; and practice payment reform. We
used this definition of PCMH in our review because it
concords strongly with the RACGP’s statement, A quality
general practice of the future,6 endorsed by all general practice
organisations nationally in 2012.
There is evidence that adoption of the PCMH model
can improve: access to care;7-107-10 clinical parameters and
outcomes;11-1511-15 management of chronic and complex dis-
ease care;7-9,11,12,14-227-9,11,12,14-22 preventive care services (eg, cho-
lesterol tests, influenza vaccinations, prostate examinati
ons);9,10,12,13,17,18,20,23-269,10,12,13,17,18,20,23-26 and provide improved condition-spe-
cific quality of care14,15,18,19,22,2714,15,18,19,22,27 and palliative care services.8
Data also indicate that the PCMH model can decrease the
use of inappropriate medications,8,22,238,22,23 and significantly
reduce avoidable hospital admissions and readmissions,
emergency department use and overall care costs.8,14,22,28-318,14,22,28-31
While the PCMH model shows promise in transforming
the primary care system into a more integrated and com-
prehensive model, studies report challenges and barriers
to the implementation and adoption of this model. Before
its potential can be achieved, more robust information is
needed on the actual change process, challenges and bar-
riers associated with implementation of this model.32,3332,33
We undertook a systematic review to identify the major
challenges and barriers to implementation and adoption
of the PCMH model. The findings from this review will
provide lessons for Australian primary health care reform
and future PCMH initiatives in Australia.
Methods
A complete description of the methods is provided in
Appendix 1 (online at mja.com.au).
In December 2012, we searched the PubMed and Embase
databases for studies published between January 2007 and
December 2012 using the search terms patient centered
medical home, patient centred medical home, medical home, or
PCMH. Appendix 2 (online at mja.com.au) provides details
of the search strategy. A snowballing strategy was used to
identify other related citations through the reference list
of all reviewed articles.
Abstracts were included if they met the following in-
clusion criteria: 1) published between 2007 and 2012; 2)
in English; 3) reported information or data related to the
Book Supplement 040814.indb 69Book Supplement 040814.indb 69 14/07/2014 10:08:28 AM14/07/2014 10:08:28 AM
2. S70 MJA 201 (3) · 4 August 2014
Supplement
review objective; 4) defined PCMH using the PCPCC Joint
Principles, or at least mentioned some of its components.5
There were no restrictions on study design or country of
study.
Articles included during the initial screening by either
reviewer underwent full-text screening. One reviewer with
expertise in the area reviewed the full text of each article
and indicated a decision to include or exclude the article for
data abstraction. We applied 10 quality criteria that were
common to sets of criteria proposed by research groups for
qualitative research (Box 1).34-3634-36 Two reviewers indepen-
dently assessed the quality of each study, and discrepancies
were resolved through discussion.
Data extraction and synthesis
A data extraction form was created by the investigative
team to assist in systematically extracting information on
the study design (type of study, methodology and setting)
and key findings related to the review objective. One re-
searcher with content knowledge in the area abstracted the
data, while a second researcher reviewed the abstracted
data alongside the original article to check for accuracy
and completeness.
Thematic synthesis was used in three stages: the free
line-by-line coding of data; the organisation of these “free
codes” into related areas to construct descriptive themes;
and the development of analytical themes.3737 Data were
configured at a study level using a top-down approach,
which allowed individual findings from broad study types
to be organised and arranged into a coherent theoretical
rendering.3838 Synthesis matrices allowed data to be recorded,
synthesised and compared.
Results
The search strategy identified 2690 citations, of which 28
studies met the inclusion criteria (Box 2). All studies were
from the US. This was not surprising, as the PCMH model
is a North American model and the PCPCC Joint Principles
of the PCMH definition we used as part of the inclusion
criteria is from the US. Of the 28 articles, there were nine
exploratory studies, 13 descriptive studies, and six experi-
mental or quasi-experimental studies. All studies met five
or more of the 10 quality criteria, and nine of the 28 studies
met all 10 quality criteria. Descriptions of included stud-
ies (including type of study, method, setting and quality
rating) are provided in Appendix 3 (online at mja.com.au).
This systematic review identified six key overlapping
challenges and barriers to implementation and adoption of
the PCMH model. These are presented below, and Appendix
4 (online at mja.com.au) includes a summary table of themes
identified in each study.
Challenges with transformation and change
management in adopting a PCMH model
Eleven studies discussed varying challenges and barriers to
transforming to a PCMH model. Transformation calls for
significant changes in the routine operations of practices,
and these are difficult to achieve and require more than a
series of incremental changes.16,27,39-4416,27,39-44 Key requirements
are: long-term commitment,17,39,43,4517,39,43,45 local variation,17,39,4517,39,45
a focus on patient-centredness,39,45,4639,45,46 and support through
reform of the larger delivery system to integrate primary
care within it.17,27,40,4717,27,40,47 Even with external payment reform,
practices need extensive assistance coaching from exter-
nal facilitators and expert consultants to transform to a
PCMH.16,27,39,4316,27,39,43
There were reported challenges41,43,44,4841,43,44,48 relating to a shift
in paradigm for individuals and practices, which required
them to move away from a physician-centred approach
towards a team approach shared among other practice
staff.17,39,43,44,4917,39,43,44,49 Transformation efforts were slowed or
ceased by ineffective change management processes;39,5039,50
lack of leadership,51,5251,52 readiness for change, communication
and trust;17,44,50-5317,44,50-53 and culture.39,43,52,5339,43,52,53 Misinformation or
lack of understanding about the PCMH could lead to misun-
derstandings about what was being asked of practices and
staff,41,45,5341,45,53 causing resistance to change.39,4339,43 Furthermore,
practices without capacity for organisational learning and
development, or what is called “adaptive reserve” (such as a
healthy relationship infrastructure, an aligned management
2 Flow diagram outlining selection process of studies for analysis
Records identified through
database searching
(n = 2690)
Additional records identified
through snowballing
(n = 3)
Records after duplicates removed
(n = 1764)
Abstracts and titles
screened for relevance
(n = 1764)
Records excluded
Lack of relevance
(n = 1604)
Conference abstract
(n = 6)
Could not locate abstract
(n = 12)
Full-text articles assessed
for eligibility
(n = 142)
Full-text articles excluded
for not including data to
address review objective
(n = 114)
Studies included in review
(n = 28)
IdentificationScreeningEligibilityIncluded
1 Criteria for assessing quality of studies34-3634-36
● Aims and objectives clearly stated
● An explicit theoretical framework, study design and/or literature review
● A clear description of context
● A clear description of the sample and how it was recruited
● A clear description of methods used to collect and analyse data
● Attempts made to establish the reliability or validity of data analysis
● Inclusion of sufficient original or synthesised data to mediate between evidence and
interpretation
● Use of verification procedure(s) to establish credibility
● Conclusions supported by results
● Relevance
Book Supplement 040814.indb 70Book Supplement 040814.indb 70 14/07/2014 10:08:28 AM14/07/2014 10:08:28 AM
3. S71MJA 201 (3) · 4 August 2014
Building a culture of co-creation in research
model and facilitated leadership), were more likely to ex-
perience “change fatigue”,17,41,43,44,50,5417,41,43,44,50,54 and less likely to
successfully implement the PCMH model.17,43,4417,43,44
Difficulties with electronic health records
Implementing an electronic health record (EHR) with a
clear, meaningful use, and which administers the princi-
ples of PCMH, has been a difficult task for primary care
practices in transition.17,41,46,5517,41,46,55 Implementation and use of
an integrated EHR has proved to be more difficult than
originally envisioned,27,39,41,43,52,5327,39,41,43,52,53 requiring significant
investment of time, effort, resources (eg, new equipment,
training material) and money.39,41,44,52,5439,41,44,52,54 Reported chal-
lenges related to setting up EHRs at practices, and providing
ongoing technical support and resources to service.
There were also difficulties with functionality (eg, EHR
could not provide data for population management; a dis-
ease registry was absent or extremely awkward to activate;
and e-visits such as telephone, email or video consultations
presented challenges), and use of EHRs (eg, accessing elec-
tronic records in a timely, easily digestible manner, and ac-
curacy and reliability of information in the EHR).39,42,48,50,5139,42,48,50,51
Furthermore, single-practice EHRs were reported as insuf-
ficient and a barrier to effective coordinated care,4747 and the
lack of interoperability of EHRs hindered collaboration
between providers, crucial to the PCMH model.17,46,47,52,5417,46,47,52,54
Challenges with funding and payment models
Sixteen studies reported challenges with the current
funding models for PCMH. Most stated that current
available funding and reimbursements were likely to be
inadequate for the transitional costs and sustainability
of the PCMH,39-42,45,49,50,54-5939-42,45,49,50,54-59 and the essential functions
of the PCMH are not supported by traditional fee struc-
tures.41,47,49,55,5641,47,49,55,56 Many studies recommended that new pay-
ment structures and incentives for practices and providers
be developed to support implementation and sustainability
of the PCMH model.39,40,43,45,49,50,52,54-5939,40,43,45,49,50,52,54-59
Insufficient practice resources and infrastructure
Eighteen studies reported barriers related to insufficient
resources within practices to implement the PCMH model.
These included lack of resources (eg, equipment, human
resources, training material), structural capabilities, time
and financial capacity to develop the necessary building
blocks to transform their practice into a PCMH.17,45,51-53,5917,45,51-53,59
Substantial support (including non-monetary support) and
resources were required to implement change at the practice
level.16,27,41,49,50,57,58,6016,27,41,49,50,57,58,60 Smaller practices typically could not
employ the same resources as larger facilities due to budget
and resources constraints. Therefore, implementation at
small practices was challenging due to lack of internal
capabilities.21,41,42,44,6121,41,42,44,61
Inadequate measures of performance and inconsistent
accreditation and standards
There were several reported challenges relating to varia-
tions in PCMH standards, inadequate accreditation and
measures of performance.16,17,39-42,45,47,5616,17,39-42,45,47,56 Most tools devel-
oped to measure achievement of the medical home did not
directly correspond to the seven Joint Principles that define
the PCMH, and many of these principles were difficult to
measure.4545 Furthermore, accreditation does not yet capture
all the key aspects required for a fully functioning medical
home,1616 and the criteria for evaluating PCMH were incon-
sistent.5656 Establishing standards, measures and targets
proved difficult.16,17,40,4216,17,40,42
Discussion
In our systematic review, we found evidence of challenges
and barriers to implementation of a PCMH model, including
difficulties with transformation to a new system, change
management issues, adopting EHRs and adapting pay-
ment models. Other challenges were inadequate resources,
performance measurement and accreditation.
Our findings have significant importance for current
Australian reform initiatives. The RACGP, as part of its
2013–14 Budget submission, called for the federal govern-
ment to fund and implement key elements of the PCMH,
as it “encapsulates the very definition of [future] general
practice in Australia”.4 Evidence-based assessment of the
barriers and enablers to such transition presented in this
article is an essential step to effective implementation.
As in the US, primary care practices in this country are
challenged by growing complexity of care, accreditation
pressures, and perverse funding and reward systems.
Clinicians and organisations are often on the receiving
end of policy implementation that is top-down rather than
bottom-up, and, as small businesses, struggle to adapt in
the defined time frames.62,6362,63 Our review also notes the
importance of reform across the larger delivery system to
integrate primary care change within it. It demonstrates
the importance of a long-term and tangible commitment
to change adoption at the practice level (strong “adaptive
reserves”), with a focus on teamwork, leadership, high-
quality communication, staff development and ongoing
support for a culture of change. Appropriate practice re-
sourcing for infrastructure and system support over the
“transformation” period is essential, as identified in our
National Primary Health Care Strategy.1,21,2
The literature also highlights the importance of practice
and practitioner funding that promotes patient centred-
ness, preventive health, and a focus on complex chronic
disease support, case management and hospital avoidance.
This is timely in the Australian context, as is the focus on
EHRs that promote care coordination, quality and safety
benchmarking, and clinical decision support.5454
Finally, our findings suggest that reform initiatives should
involve accreditation review, such that these frameworks
reflect measures of performance and standards that match
the key benchmarks of importance, with minimal admin-
istrative barriers. Such initiatives are in early development,
with the RACGP and Australian Commission on Quality
and Safety in Health Care partnering in a review of ac-
creditation process and outcome.6464
Our review had some limitations. The search strategy
did not include grey literature, and unpublished evalua-
tion studies or reports may have been missed. There could
also be other challenges or barriers not reported in the
reviewed publications. The review was limited to studies
that used the Joint Principles,5 because this definition con-
cords strongly with the RACGP’s A quality general practice
of the future,6 but may have missed literature published
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4. S72 MJA 201 (3) · 4 August 2014
Supplement
outside this definition. Data abstraction from qualitative
studies can be complicated by the varied reporting styles.6565
Relevant study “data” were often not presented in the results
section, but integrated into the discussion or recommen-
dations. Hence, a second researcher reviewed abstracted
data alongside the original article to check for accuracy
and completeness. Furthermore, the synthesis of qualita-
tive data is problematic and dependent on the judgement
and insight of the researchers (interpretation bias).37,66,6737,66,67
To limit this bias, two independent researchers were used
in the synthesis process.
Our systematic review indicates that implementation
of significant primary care change should be cognisant of
several considerations, mostly at the practice–practitioner
interface. It comes at an important juncture for Australian
health care reform, with reviews into the personally con-
trolled electronic health record and Medicare Locals, and
recent ministerial statements regarding funding reform
for chronic disease management likely to have a major
impact on the sector. For policymakers, they underline the
approach and resourcing required to effectively influence
service delivery. For clinicians, they highlight the teamwork,
commitment and practice infrastructure critical to suc-
cess. Australian health care reforms demand “a stronger,
more robust primary health care system”.2 Addressing
documented barriers to change adoption relevant in the
Australian context will be a critical evidence-into-policy
initiative.
Acknowledgements: We thank the Australian Primary Health Care Research Institute
for funding this commissioned research, Lars Eriksson (University of Queensland) for
assistance with the literature searches, and Susan Upham (University of Queensland,
Discipline of General Practice) for assisting with this systematic review as a second
reviewer assessing the quality of studies.
Competing interests: No relevant disclosures.
Provenance: Commissioned; externally peer reviewed.
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