Early Patient-Centered Outcomes Research Experience With the Use of Telehealth to Address Disparities: Scoping Review.

BACKGROUND: Health systems and providers across America are increasingly employing telehealth technologies to better serve medically underserved low-income, minority, and rural populations at the highest risk for health disparities. The Patient-Centered Outcomes Research Institute (PCORI) has invested US $386 million in comparative effectiveness research in telehealth, yet little is known about the key early lessons garnered from this research regarding the best practices in using telehealth to address disparities. OBJECTIVE: This paper describes preliminary lessons from the body of research using study findings and case studies drawn from PCORI seminal patient-centered outcomes research (PCOR) initiatives. The primary purpose was to identify common barriers and facilitators to implementing telehealth technologies in populations at risk for disparities. METHODS: A systematic scoping review of telehealth studies addressing disparities was performed. It was guided by the Arksey and O'Malley Scoping Review Framework and focused on PCORI's active portfolio of telehealth studies and key PCOR identified by study investigators. We drew on this broad literature using illustrative examples from early PCOR experience and published literature to assess barriers and facilitators to implementing telehealth in populations at risk for disparities, using the active implementation framework to extract data. Major themes regarding how telehealth interventions can overcome barriers to telehealth adoption and implementation were identified through this review using an iterative Delphi process to achieve consensus among the PCORI investigators participating in the study. RESULTS: PCORI has funded 89 comparative effectiveness studies in telehealth, of which 41 assessed the use of telehealth to improve outcomes for populations at risk for health disparities. These 41 studies employed various overlapping modalities including mobile devices (29/41, 71%), web-based interventions (30/41, 73%), real-time videoconferencing (15/41, 37%), remote patient monitoring (8/41, 20%), and store-and-forward (ie, asynchronous electronic transmission) interventions (4/41, 10%). The studies targeted one or more of PCORI's priority populations, including racial and ethnic minorities (31/41, 41%), people living in rural areas, and those with low income/low socioeconomic status, low health literacy, or disabilities. Major themes identified across these studies included the importance of patient-centered design, cultural tailoring of telehealth solutions, delivering telehealth through trusted intermediaries, partnering with payers to expand telehealth reimbursement, and ensuring confidential sharing of private information. CONCLUSIONS: Early PCOR evidence suggests that the most effective health system- and provider-level telehealth implementation solutions to address disparities employ patient-centered and culturally tailored telehealth solutions whose development is actively guided by the patients themselves to meet the needs of specific communities and populations. Further, this evidence shows that the best practices in telehealth implementation include delivery of telehealth through trusted intermediaries, close partnership with payers to facilitate reimbursement and sustainability, and safeguards to ensure patient-guided confidential sharing of personal health information.

Addressing Implementation Challenges to Digital Care Delivery for Adults With Multiple Chronic Conditions: Stakeholder Feedback in a Randomized Controlled Trial.

BACKGROUND: Digital tools accessed via smartphones can promote chronic condition management, reduce disparities in health care and hospital readmissions, and improve quality of life. However, whether digital care strategies can be implemented successfully on a large scale with traditionally underserved populations remains uncertain. OBJECTIVE: As part of a randomized trial comparing care delivery strategies for Medicaid and Medicare-Medicaid beneficiaries with multiple chronic conditions, our stakeholders identified implementation challenges, and we developed stakeholder-driven adaptions to improve a digitally delivered care management strategy (high-tech care). METHODS: We used 4 mechanisms (study support log, Patient Partners Work Group log, case interview log, and implementation meeting minutes) to capture stakeholder feedback about technology-related challenges and solutions from 9 patient partners, 129 participants, and 32 care managers and used these data to develop and implement solutions. To assess the impact, we analyzed high-tech care exit surveys and intervention engagement outcomes (video visits and condition-specific text message check-ins sent at varying intervals) before and after each solution was implemented. RESULTS: Challenges centered around 2 themes: difficulty using both smartphones and high-tech care components and difficulty using high-tech care components due to connectivity issues. To respond to the first theme's challenges, we devised 3 solutions: tech visits (eg, in-person technology support visits), tech packet (eg, participant-facing technology user guide), and tailored condition-specific text message check-ins. During the first 20 months of implementation, 73 participants received at least one tech visit. We observed a 15% increase in video call completion for participants with data before and after the tech visit (n=25) and a 7% increase in check-in completion for participants with data before and after the tech visit (n=59). Of the 379 participants given a tech packet, 179 completed care during this timeframe and were eligible for an exit survey. Of the survey respondents, 76% (73/96) found the tech packet helpful and 64% (62/96) actively used it during care. To support condition-specific text message check-in completion, we allowed for adaption of day and/or time of the text message with 31 participants changing the time they received check-ins and change in standard biometric settings with 13 physicians requesting personalized settings for participants. To respond to the second theme's challenges, tech visits or phone calls were made to demonstrate how to use a smartphone to connect or disconnect from the internet, to schedule video calls, or for condition-specific text message check-ins in a location with broadband/internet. CONCLUSIONS: Having structured stakeholder feedback mechanisms is key to identify challenges and solutions to digital care engagement. Creating flexible and scalable solutions to technology-related challenges will increase equity in accessing digital care and support more effective engagement of chronically ill populations in the use of these digital care tools. TRIAL REGISTRATION: ClinicalTrials.gov NCT03451630; https://clinicaltrials.gov/ct2/show/NCT03451630.

Correction: Addressing Implementation Challenges to Digital Care Delivery for Adults With Multiple Chronic Conditions: Stakeholder Feedback in a Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/23498.].

Stakeholder impact on the implementation of integrated care: Opportunities to consider for patient-centered outcomes research.

Nearly half of Americans live with chronic disease. Many have multiple chronic conditions that often present as a combination of physical and mental health conditions. Aligning stakeholder-driven, patient-centered outcomes research with population health strategies such as innovative ways to deliver care management can reduce the burden of multiple chronic conditions. In addition, successfully creating meaningful, inclusive research requires actively engaging stakeholders throughout the lifecycle of a study. This study integrates stakeholder engagement, using a large health plan in western Pennsylvania, to conduct a randomized controlled trial. Three care management strategies, High-Touch, High-Tech, and Usual Care, are compared for effectiveness among members with multiple chronic conditions. Care strategies are delivered via the Community Team, a multidisciplinary community-based team, offering in-person (High-Touch) and digital (High-Tech) care management in 14 counties across Pennsylvania. Participants are followed for 12months, with repeated measurements of self-reported health status and activation in care, while tracking administrative measurements of primary and specialty health service utilization. Quality of life, care satisfaction, engagement in care, and service utilization will be compared using generalized mixed models. Additionally, semi-structured interviews are conducted for both participants and care managers over the course of the study to evaluate feasibility. This manuscript presents implementation strategies, while noting that the implementation of patient-centered outcomes research in a real-world setting requires rapid evaluation, redesign of workflow, and tailored approaches for success.

MyVA Access: An Evaluation of Changes in Access for a System-Wide Program Implemented in the Veterans Health Administration.

The current study evaluates changes in access as a result of the MyVA Access program-a system-wide effort to improve patient access in the Veterans Health Administration. Data on 20 different measures were collected, and changes were analyzed using t tests and Chow tests. Additionally, organizational health-how able a system is to create health care practice change-was evaluated for a sample of medical centers (n = 36) via phone interviews and surveys conducted with facility staff and technical assistance providers. An organizational health variable was created and correlated with the access measures. Results showed that, nationally, average wait times for urgent consults, new patient wait times for mental health and specialty care, and slot utilization for primary and specialty care patients improved. Patient satisfaction measures also improved, and patient complaints decreased. Better organizational health was associated with improvements in patient access.

Screening, Brief Intervention, and Referral to Treatment in the Emergency Department: An Examination of Health Care Utilization and Costs.

BACKGROUND: There is increasing interest in deploying screening, brief intervention, and referral to treatment (SBIRT) practices in emergency departments (ED) to intervene with patients at risk for substance use disorders. However, the current literature is inconclusive on whether SBIRT practices are effective in reducing costs and utilization. OBJECTIVE: This study sought to evaluate the health care costs and health care utilization associated with SBIRT services in the ED. RESEARCH DESIGN: This study analyzed downstream health care utilization and costs for patients who were exposed to SBIRT services within an Allegheny County, Pennsylvania, ED through a program titled Safe Landing compared with 3 control groups of ED patients (intervention hospital preintervention, and preintervention and postintervention time period at a comparable, nonintervention hospital). SUBJECTS: The subjects were patients who received ED SBIRT services from January 1 to December 31 in 2012 as part of the Safe Landing program. One control group received ED services at the same hospital during a previous year. Two other control groups were patients who received ED services at another comparable hospital. MEASURES: Measures include total health care costs, 30-day ED visits, 1-year ED visits, inpatient claims, and behavioral health claims. RESULTS: Results found that patients who received SBIRT services experienced a 21% reduction in health care costs and a significant reduction in 1-year ED visits (decrease of 3.3 percentage points). CONCLUSIONS: This study provides further support that SBIRT programs are cost-effective and cost-beneficial approaches to substance use disorders management, important factors as policy advocates continue to disseminate SBIRT practices throughout the health care system.

A statewide screening, brief intervention, and referral to treatment (SBIRT) curriculum for medical residents: Differential implementation strategies in heterogeneous medical residency programs.

BACKGROUND: Many screening, brief intervention, and referral to treatment (SBIRT) training curricula have been implemented within graduate medical residency training programs, with varying degrees of success. The authors examined the implementation of a uniform, but adaptable, statewide SBIRT curriculum in 7 diverse residency training programs and whether it could improve resident knowledge, skills, and attitudes regarding SBIRT and unhealthy alcohol and other drug (AOD) use. METHODS: The authors assessed the implementation of the Pennsylvania SBIRT Medical and Residency Training (SMaRT) curriculum at 7 residency sites training a variety of disciplines. Faculty could use a variety of training modalities, including (1) Web-based self-directed modules; (2) didactic lectures; (3) small-group sessions; and/or (4) skill-transfer interactions with standardized or real patients in preceptor-led encounters. Acquisition of knowledge, skills, and attitudes regarding SBIRT and unhealthy AOD use-associated patient care were assessed via a pre- and post-survey instrument with 4 domains: Resident Knowledge, Resident Competence, Resident Skills and Attitudes (Alcohol), and Resident Skills and Attitudes (Drug). Responses to the pre- and post-surveys (N = 365) were compared and analyzed with t tests and Wilcoxon signed-rank tests. RESULTS: The diverse modalities allowed each of the residency programs to adapt and implement the SMaRT curriculum based on their needs and environments. Residents' knowledge, skills, and attitudes regarding SBIRT and working with unhealthy AOD use, as assessed by survey, generally improved after completing the SMaRT curriculum, despite the variety of models used. Specifically, Resident Knowledge and Resident Competence domains significantly improved (P < .000). Residents improved the least for survey items within the Resident Skills and Attitudes (Alcohol) domain. CONCLUSIONS: Adaptable curricula, such as SMaRT, may be a viable step towards developing a nationwide curriculum.

The pharmacist's role in overdose: Using mapping technologies to analyze naloxone and pharmacy distribution.

OBJECTIVES: To present preliminary research using geographic information system (GIS) mapping as a tool that can be integrated into pharmacy practice to increase access to and utilization of pharmacy-based interventions, including the distribution of naloxone. METHODS: Overdose death data was collected from medical examiner reports in an online database, and pharmacies carrying and distributing naloxone were determined by ZIP Code Tabulation Areas (ZCTAs) in Allegheny County, PA. The distribution of overdose death rates was analyzed in relation to naloxone-carrying pharmacies and all licensed pharmacies in the county with the use of GIS mapping. RESULTS: Eighty-seven ZCTAs were included. Of 322 active licensed pharmacies, 28 pharmacies were confirmed to carry and distribute naloxone. The number of overdose deaths in ZCTAs that have naloxone-distributing pharmacies was significantly higher than the average number of deaths in all ZCTAs in Allegheny County: 7.38 deaths versus 4.84 deaths, respectively (P = 0.021). CONCLUSION: This report illustrates the value of GIS mapping in monitoring the impact of overdose death prevention efforts, including the availability of naloxone in pharmacies. Analysis of these data over the next 5 years will provide valuable information on the potential impact of naloxone-distributing pharmacies on overdose rates, which, in turn, will inform pharmacists and pharmacy organizations on the value of carrying naloxone in pharmacies and inform local communities of its availability.

Evaluating the Impact of Sample Medication on Subsequent Patient Adherence.

BACKGROUND: Medication nonadherence is problematic throughout health care practice. Patient nonadherence is a result of several factors, such as financial issues, confusion about the medication, or concerns about possible side effects. Efforts to improve adherence have been implemented, but new strategies are needed to ensure that patients fill their medication prescriptions and adhere to their prescribed use. OBJECTIVE: To investigate whether providing patients with a free 30-day supply of medication at the point of care via a dispensing kiosk-a secure, computerized cabinet placed in the prescriber's office-that provides sample medication and educational materials had a measurable impact on adherence and health care cost. METHODS: The study sample consisted of patients drawn from the electronic health records of a large health care provider who were prescribed medications to treat diabetes, hypertension, and dyslipidemia. The comparison groups included a treatment group of patients who each received a 30-day generic sample of medication and a control group of patients who did not receive a sample. The study outcome was primary medication non-adherence (PMN), defined as whether a patient filled a prescription within 90, 180, or 365 days of prescribing. Only patients receiving a prescription for the first time were considered; patients on a medication before receipt of the sample were dropped. Postprescription medication adherence (PPMA), measured as proportion of days covered (PDC) and proportion of days covered ≥ 80% (PDC80), was also examined. Propensity score methods and multivariate regression models were used to examine the outcomes and group differences. Costs to the patient before and after the prescription were also analyzed. Key informant interviews were conducted with physicians, and qualitative analyses were performed. RESULTS: Patients who received a 30-day generic medication sample had a higher probability of filling a first prescription within 90 days (72.2% for treatment patients vs. 37.6% for controls, P < 0.001); 180 days (79.1% vs. 43.3%, respectively, P < 0.001); and 365 days (85.5% vs. 48.6%, P < 0.001). The medication sample had a positive effect on PDC for 90 days, with treatment patients having 72.8% adherent days versus 35.1% adherent days for controls (average treatment effect [ATE] = 37.5%, P < 0.001). At 180 days, PDC adherence was 57.1% for treatment patients versus 35.4% for controls (ATE = 21.5%, P < 0.001), and 43.6% versus 33.9%, respectively (ATE = 9.5%, P < 0.001) for the 365-day period. PDC80 was significantly better among treatment patients at 90 days (53.5% vs. 31.2%, respectively, ATE = 22.4%, P < 0.001) and 180 days (38.4% vs. 29.1%, ATE = 9.2%, P < 0.001), but not at 365 days (23.7% vs. 23.7%, ATE = -0.02, not significant). Costs were reduced by $395 for the treatment group. Interviews with clinicians indicated a positive view of the program. CONCLUSIONS: Providing a free sample medication improved the probability of patients filling their initial prescriptions and adhering to those medications. This program can affect health care costs, as evidenced by lower costs for the treatment group. DISCLOSURES: Financial support for this study was provided by MedVantx. UMPC Health Plan reviewed and commented on the manuscript. Hogue is an employee of MedVantx and also reviewed the manuscript. Manolis is employed by UPMC Health Plan. The remaining authors report no other conflicts of interest. Study concept and design were contributed by Pringle. Aldridge took the lead in data collection, along with Kearney. Data interpretation was performed primarily by Radack, along with Kearney and Grasso. The manuscript was written by Kearney, Aldridge, and Radack and revised by Kearney, Manolis, Hogue, and Radack.

The Association of Job Strain With Medication Adherence: Is Your Job Affecting Your Compliance With a Prescribed Medication Regimen?

OBJECTIVE: This innovative study examines for the first time the relationship between occupational factors (eg, job strain) and medication adherence. METHODS: An analysis of secondary data collected from a randomized controlled trial (RCT) implemented in 34 drugstores of a national pharmacy chain in Tennessee. Medication adherence, health care utilization, psychosocial assessment, chronic disease status, and occupational health history data were obtained from study participants. RESULTS: The study found that most job strains are less adherent to their medication regimen as measured by proportion of days covered (PDC) than those in a low strain job category. However, statistically significant differences are observed only for renin angiotensin system antagonists (RASA), statins, and when PDC is combined across all medication classes. CONCLUSIONS: Examining occupational factors may prove beneficial in developing interventions that improve medication adherence.

User testing and performance evaluation of the Electronic Quality Improvement Platform for Plans and Pharmacies.

OBJECTIVE: To user-test and evaluate a performance information management platform that makes standardized, benchmarked medication use quality data available to both health plans and community pharmacy organizations. SETTING: Multiple health/drug plans and multiple chain and independent pharmacies across the United States. EVALUATION: During the first phase of the study, user experience was measured via user satisfaction surveys and interviews with key personnel (pharmacists, pharmacy leaders, and health plan leadership). Improvements were subsequently made to the platform based on these findings. During the second phase of the study, the platform was implemented in a greater number of pharmacies and by a greater number of payers. User experience was then reevaluated to gather information for further improvements. RESULTS: The surveys and interviews revealed that users found the Web-based platform easy to use and beneficial in terms of understanding and comparing performance metrics. Primary concerns included lack of access to real-time data and patient-specific data. Many users also expressed uncertainty as to how they could use the information and data provided by the platform. CONCLUSION: The study findings indicate that while information management platforms can be used effectively in both pharmacy and health plan settings, future development is needed to ensure that the provided data can be transferred to pharmacy best practices and improved quality care.