Funding Learning Health System Research: Challenges and Strategies.

PURPOSE: A growing number of health systems are establishing learning health system (LHS) programs, where research focuses on rapidly improving the health system's internal operations and performance. The authors examine funding challenges facing such initiatives and identify strategies for managing tensions between reliance on external research funding and directly contributing to improvement and learning within the researchers' own system. METHOD: Qualitative case studies of LHS research programs in 5 health systems were performed via 38 semistructured interviews (October 2019-April 2021) with 35 diverse respondents. Inductive and deductive rapid qualitative analysis supported interview, system-level, and cross-system summaries and analysis. RESULTS: External funding awards to LHS researchers facilitated some internal improvement and learning, scientific advancements, and the reputation of researchers and their systems, but reliance on external funding also challenged researchers' responsiveness to concerns of system leaders, managers, practitioners, and system needs. Gaps between external funding requirements and internally focused projects arose in objectives, practical applicability, audiences, timetables, routines, skill sets, and researchers' careers. To contribute more directly to system improvement, LHS researchers needed to collaborate with clinicians and other nonresearchers and pivot between long research studies and shorter, dynamic improvement, evaluation, and data analysis projects. With support from system executives, LHS program leaders employed several strategies to enhance researchers' internal contributions. They aligned funded-research topics with long-term system needs, obtained internal funding for implementing and sustaining practice change, and diversified funding sources. CONCLUSIONS: To foster LHS research contributions to internal system learning and improvement, LHS program leaders need to manage tensions between concentrating on externally funded research and fulfilling their mission of providing research-based services to their own system. Health system executives can support LHS programs by setting clear goals for them; appropriately staffing, budgeting, and incentivizing LHS researchers; and developing supportive, system-wide teamwork, skill development programs, and data infrastructures.

How alignment between health systems and their embedded research units contributes to system learning.

BACKGROUND: There is growing interest in the contributions of embedded, learning health system (LHS), research within healthcare delivery systems. We examined the organization of LHS research units and conditions affecting their contributions to system improvement and learning. METHODS: We conducted 12 key-informant and 44 semi-structured interviews in six delivery systems engaged in LHS research. Using rapid qualitative analysis, we identified themes and compared: successful versus challenging projects; LHS units and other research units in the same system; and LHS units in different systems. RESULTS: LHS units operate both independently and as subunits within larger research centers. Contributions of LHS units to improvements and learning are influenced by alignment of facilitating factors within units, within the broader system, and between unit and host system. Key alignment factors were availability of internal (system) funding directing researchers' work toward system priorities; researchers' skills and experiences that fit a system's operational needs; LHS unit subculture supporting system improvement and collaboration with clinicians and other internal stakeholders; applications of external funding to system priorities; and executive leadership for system-wide learning. Mutual understanding and collaboration between researchers, clinicians, and leaders was fostered through direct consultation between LHS unit leaders and system executives and engagement of researchers in clinical and operational activities. CONCLUSIONS: Embedded researchers face significant challenges to contributing to system improvement and learning. Nevertheless, when appropriately led, organized, and supported by internal funding, they may learn to collaborate effectively with clinicians and system leaders in advancing care delivery toward the learning health system ideal.

Incorporation of Social Risk in US Preventive Services Task Force Recommendations and Identification of Key Challenges for Primary Care.

IMPORTANCE: In its mission to improve health, the US Preventive Services Task Force (USPSTF) recognizes the strong relationship between a person's health and social and economic circumstances as well as persistent inequities in health care delivery. OBJECTIVE: To assess how social risks have been considered in USPSTF recommendation statements and identify current gaps in evidence needed to expand the systematic inclusion of social risks in future recommendations. EVIDENCE: The USPSTF commissioned a technical brief that reviewed existing literature on screening and interventions for social risk factors and also audited the 85 USPSTF recommendation statements active as of December 2019 to determine how social risks were addressed in clinical preventive services recommendations. FINDINGS: Among the 85 USPSTF recommendation statements reviewed, 14 were focused on preventive services that considered health-related social risks. Social risks were commonly referenced in parts of USPSTF recommendations, with 57 of 85 recommendations including some comment on social risks within the recommendation statement, although many comments were not separate prevention services. Social risks were commented on in USPSTF recommendations as part of risk assessment, as a marker of worse health outcomes from the condition of focus, as a consideration for clinicians when implementing the preventive service, and as a research need or gap on the topic. CONCLUSIONS AND RELEVANCE: This report identified how social risks have been considered in the USPSTF recommendation statements. It serves as a benchmark and foundation for ongoing work to advance the goal of ensuring that health equity and social risks are incorporated in USPSTF methods and recommendations.

Understanding the characteristics of US cancer survivors with informal caregivers.

BACKGROUND: Although informal caregivers such as family and friends provide people with cancer needed physical care and emotional support, little is known about which individuals have access to such caregivers. The purpose of this article is to provide a nationally representative description of the sociodemographic characteristics of cancer survivors who have or had an informal caregiver in the United States. METHODS: Cross-sectional data were taken from the Experiences With Cancer Survivorship Supplement of the Medical Expenditure Panel Survey in 2011, 2016, and 2017. People were cancer survivors from diagnosis until the end of life. The study population consisted of adult survivors of cancer other than nonmelanoma skin cancer who were treated for cancer less than 3 years before the survey and were living in the community (n = 720). The main outcome measure was whether or not the cancer survivor reported having an informal caregiver. RESULTS: In the United States, 55.2% of cancer survivors reported having an informal caregiver during or after their cancer treatment. The relationship of the caregiver to the survivor varied by sex: males were more likely to have a spouse as their caregiver, and females were more likely to have a child as their caregiver. In multivariate analyses, cancer survivors who were female, were married, were of a race/ethnicity other than White, or were in poor health were more likely to have an informal caregiver. CONCLUSIONS: Future research can examine whether those without informal caregivers might need more formal support as they undergo cancer treatment and transition into cancer survivorship.

Developing Primary Care-Based Recommendations for Social Determinants of Health: Methods of the U.S. Preventive Services Task Force.

The purpose of the U.S. Preventive Services Task Force (USPSTF) is to provide evidence-based recommendations on primary care screening, behavioral counseling, and preventive medications. A person's health is strongly influenced by social determinants of health, such as economic and social conditions; therefore, preventive recommendations that address these determinants would be ideal. However, differing social determinants have been proposed by a wide range of agencies and organizations, little prevention evidence is available, and responsible parties are in competition, all of which make the creation of evidence-based prevention recommendations for social determinants of health challenging. This article highlights social determinants already included in USPSTF recommendations and proposes a process by which others may be considered for primary care preventive recommendations. In many ways, incorporating social determinants of health into evidence-based recommendations is an evolving area. By reviewing the evidence on the effects of screening and interventions on social determinants relevant to primary care, the USPSTF will continue to provide recommendations on clinical preventive services to improve the health of all Americans.

How the U.S. Agency for Healthcare Research and Quality Promotes Health Literate Health Care.

This report traces the U.S. Agency for Healthcare Research and Quality's (AHRQ) strategic approach to promote health literate health care delivery systems. For almost 15 years, the AHRQ Health Literacy Action Plan has served as the framework for the Agency's efforts to: 1) Develop Measures; 2) Improve the Evidence Base and Create Implementation Tools; 3) Create and Support Change; 4) Disseminate and Transfer Knowledge and Tools; and 5) Practice What We Preach. Drawing upon its core competencies in data and measurement, practice improvement, and health services research, AHRQ accelerated the uptake of evidence-based health literacy strategies by health care organizations.

Rural Residents With Mental Health Needs Have Fewer Care Visits Than Urban Counterparts.

Analysis of a nationally representative sample of adults with mental health needs shows that rural residents have fewer ambulatory mental health visits than their urban counterparts do. Even among people already on prescription medications for mental health conditions, rural-urban differences are large.

Statin Use in the U.S. for Secondary Prevention of Cardiovascular Disease Remains Suboptimal.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) remains the leading cause of mortality in the United States. The purpose of this study is to examine the rates of statin use for secondary prevention of ASCVD events in the United States over the last decade and determine whether disparities in the treatment of ASCVD still persist among women and racial/ethnic minorities. METHODS: We conducted a trend analysis using data from 2008 through 2016 to describe age-adjusted trends in the use of statins for secondary prevention using the Medical Expenditure Panel Survey. We also conducted a multivariable logistic regression analysis to determine whether sociodemographic characteristics are associated with statin use during the 3 years that followed the publication of the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guideline (2014 through 2016). RESULTS: The prevalence of statin use among those with a history of ASCVD remained unchanged from 2008 through 2016. In 2014 to 2016, more than 40% of those aged 40 years and older with a history of ASCVD did not use statins, corresponding to approximately 9.5 million Americans. Increasing age and having been diagnosed with high cholesterol (odds ratio [OR], 6.22; P < .001) were associated with higher odds of statin use while being female (OR, 0.65; P < .001) or Hispanic (OR, 0.69; P = .011) were associated with lower odds of statin use. CONCLUSIONS: Our study found there was no increase in the national rates of statin use following the ACC/AHA 2013 secondary prevention guideline and the availability of generic statins. Significant gender and ethnic disparities in ASCVD treatment remained in the United States.

The Practice Gap: National Estimates of Screening and Counseling for Alcohol, Tobacco, and Obesity.

Tobacco use, lack of physical activity and poor diet, and alcohol consumption are leading causes of death in the United States. We estimated screening and counseling rates by using a nationally representative sample of adults aged 35 years and older with a preventive care supplement to the 2014 Medical Expenditure Panel Survey. Receipt of the recommended level of services ranged from nearly two-thirds (64.2% for obesity, 61.9% for tobacco use) to less than one-half (41.0% for alcohol misuse). There is significant room for improving care delivery, but primary care practices probably also need additional resources to raise screening and counseling rates.

Next Steps in Improving Healthcare Value: AHRQ Evidence-based Practice Center Program-Applying the Knowledge to Practice to Data Cycle to Strengthen the Value of Patient Care.

For more than 20 years, the Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) Program has been identifying and synthesizing evidence to inform evidence-based healthcare. Recognizing that many healthcare settings continue to face challenges in disseminating and implementing evidence into practice, AHRQ's EPC program has also embarked on initiatives to facilitate the translation of evidence into practice and to measure and monitor how practice changes impact health outcomes. The program has structured its efforts around the three phases of the Learning Healthcare System cycle: knowledge, practice, and data. Here, we use a topic relevant to the field of hospital medicine-Clostridium difficile colitis prevention and treatment-as an exemplar of how the EPC program has used this framework to move evidence into practice and develop systems to facilitate continuous learning in healthcare systems.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services.

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

Missed Opportunities for Depression Screening and Treatment in the United States.

PURPOSE: This study estimates the prevalence of depression assessment in adults age 35 and older and how prevalence varies by sociodemographic characteristics and depressive symptoms. METHODS: We used a nationally representative survey, the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey, to evaluate if adults 35+ were being assessed for depression by their health care providers in 2014 and 2015. Using multivariate logistic regression, we examined the health and sociodemographic characteristics of patients associated with depression assessment. RESULTS: Approximately 50% of US adults aged 35+ were being assessed for depression (48.6%; 95% CI, 45.5%-51.6%). The following were less likely to be assessed: men compared with women (OR, 0.58; 95% CI, 0.46-0.72), adults 75+ compared with adults 50 to 64 years old (OR, 0.47; 95% CI, 0.32-0.69), the uninsured compared with those with private insurance (OR, 0.30; 95% CI, 0.18-0.51), and adults without recognized depressive symptoms compared with those with recognized symptoms (OR, 0.39; 95% CI, 0.24-0.63). Compared with non-Hispanic whites, the following were less likely to be assessed: Asian (OR, 0.35; 95% CI, 0.19-0.67), Hispanic (OR, 0.47; 95% CI, 0.29-0.75), and African American (OR, 0.42; 95% CI, 0.27-0.67). CONCLUSIONS: Many Americans are not having their depression needs assessed. Certain populations are more likely to be missed, including men, people over 75 years old, minorities, and the uninsured. Additional efforts are needed to determine methods to increase screening recommended by the United States Preventive Services Task Force and to ensure that all Americans have their mental health needs met.

Raising a Red Flag on Dating Violence: Evaluation of a Low-Resource, College-Based Bystander Behavior Intervention Program.

Encouraging bystanders to intervene safely and effectively in situations that could escalate to violence-known as bystander behavior programs-is a growing yet largely untested strategy to prevent dating violence. Using a quasi-experimental design, we evaluate a low-resource, low-intensity intervention aimed at preventing dating violence among college students. The integrated behavioral model (IBM) was used to guide the evaluation. We also assess which IBM variables were most strongly associated with bystander behaviors. Participants were drawn from two Virginia colleges that predominantly train females in the health profession sciences. The intervention group ( n = 329) participated in a university-wide bystander behavior intervention consisting of a 30-min presentation on dating violence at new-student orientation and a week-long "red flag" social marketing campaign on campus to raise awareness of dating violence. Controlling for changes at the comparison university, results showed an increase in bystander behaviors, such as encouraging a friend who may be in an abusive relationship to get help, after the intervention and adjusting for potential confounders (increase of 1.41 bystander behaviors, p = .04). However, no significant changes were found for bystander intentions, self-efficacy, social norms, or attitudes related to dating violence from pre- to post-intervention. Self-efficacy had a direct relationship with bystander behaviors. Results suggest that low-resource interventions have a modest effect on increasing bystander behaviors. However, higher resource interventions likely are needed for a larger impact, especially among students who already demonstrate strong baseline intentions to intervene and prevent dating violence.

U.S. Preventive Services Task Force Methods to Communicate and Disseminate Clinical Preventive Services Recommendations.

The U.S. Preventive Services Task Force (USPSTF) issues evidence-based screening and prevention recommendations, and key to this task is dissemination and implementation of these recommendations. The Task Force has recommendations for more than 84 topics; each USPSTF Recommendation Statement includes a letter grade, a topline summary to guide clinician interpretation in practice, and a summary of gaps in evidence to help catalyze clinically relevant research. The USPSTF aims to update existing topics regularly and considers new topics to add each year. Clearly communicating and disseminating each recommendation is a critical task to ensure maximum benefit from use of the recommendations. The primary USPSTF audience is primary care clinicians. Over time, other audiences have become interested in the USPSTF and these entities have broad and diverse needs, necessitating a range of communication platforms and approaches. This includes engagement with and input from topic experts, primary care and federal partners, and the public to help shape the development of the recommendations. It also includes engagement of partners to disseminate USPSTF recommendations to help ensure that the primary care workforce remains up-to-date on USPSTF recommendations. This paper outlines the approaches used by the USPSTF to both solicit input (e.g., public comment periods), as well as to facilitate dissemination of its recommendations to help improve the health of all Americans (e.g., web-based and mobile application tools, journal publications, and annual reports to Congress).

Health researcher views on comparative effectiveness research and research engagement.

AIM: To understand researcher capability for and interest in patient-centered comparative effectiveness research (PC-CER), particularly related to engaging with patients/caregivers. MATERIALS & METHODS: Web-based survey of 508 health researchers recruited via professional health research organizations. RESULTS: Most respondents (94%) were familiar with CER and many (69%) reported having previously conducting some form of CER. Most respondents were familiar with (81%) and interested in (87%) partnering with patients and/or caregivers in research. Resources to assist in training, coordination of partners, guidance in apply for funding and improved infrastructure were commonly cited factors that would help researchers conduct PC-CER. CONCLUSION: There is a significant opportunity for researchers to engage patients and caregivers as partners in CER. Researchers recognize the need for additional training and expertise to leverage those opportunities.