Association of Implementation and Social Network Factors With Patient Safety Culture in Medical Homes: A Coincidence Analysis.

OBJECTIVES: The patient-centered medical home (PCMH) may provide a key model for ambulatory patient safety. Our objective was to explore which PCMH and patient safety implementation and social network factors may be necessary or sufficient for higher patient safety culture. METHODS: This was a cross-case analysis study in 25 diverse U.S. PCMHs. Data sources included interviews of a clinician and an administrator in each PCMH, surveys of clinicians and staff, and existing data on the PCMHs' characteristics. We used coincidence analysis, a novel method based on set theory and Boolean logic, to evaluate relationships between factors and the implementation outcome of patient safety culture. RESULTS: The coincidence analysis identified 5 equally parsimonious solutions (4 factors), accounting for all practices with higher safety culture. Three solutions contained the same core minimally sufficient condition: the implementation factor leadership priority for patient safety and the social network factor reciprocity in advice-seeking network ties (advice-seeking relationships). This minimally sufficient condition had the highest coverage (5/7 practices scoring higher on the outcome) and best performance across solutions; all included leadership priority for patient safety. Other key factors included self-efficacy and job satisfaction and quality improvement climate. The most common factor whose absence was associated with the outcome was a well-functioning process for behavioral health. CONCLUSIONS: Our findings suggest that PCMH safety culture is higher when clinicians and staff perceive that leadership prioritizes patient safety and when high reciprocity among staff exists. Interventions to improve patient safety should consider measuring and addressing these key factors.

ECHO: A Model for Professional Development in Nursing Through Learning Networks.

Health research is published at a breathtaking pace and quantity; however, even when research is systematically developed into best practices and/or clinical guidelines, it often is not implemented into practice. Project ECHO (Extension for Community Healthcare Outcomes) is an evidence-based professional development approach that can help nurses to stay current and apply new knowledge to practice. The purpose of this article is to describe ECHO as a model for professional development and capacity building through learning networks. This article describes the ECHO model, evidence supporting its use, the infrastructure needed to implement an ECHO network, and two nursing ECHO learning networks. [J Contin Educ Nurs. 2021;52(4):198-204.].

A Comparison of the Influence of Anticipated Death Trajectory and Personal Values on End-of-Life Care Preferences: A Qualitative Analysis.

OBJECTIVES: We examined anticipated preferences for end-of-life (EOL) care in healthy older adults in the context of various terminal disease scenarios to explore the relationship between personal values and diseases and conditions that would influence EOL care choices. METHODS: Qualitative Descriptive Analysis was used to derive themes and the relationship between EOL preference themes and personal value themes in 365 respondents in a national sample of healthy older adults who completed a survey on their anticipated preferences for end-of-life (EOL) care. RESULTS: Reluctance to burden close others was the most frequently voiced personal value across all conditions affecting EOL preferences, followed by the personal value of quality of life. Concern about whether one's wishes would be honored was more commonly voiced in the context of hypothetical, prospective terminal cancer than in neurological conditions. Respondents who voiced desire for autonomy in how they would die clearly attributed extreme pain as the primary influence on EOL preferences. CONCLUSIONS: Comprehensive assessment of patient personal values should include consideration of particular chronic disease scenarios and death trajectories to fully inform EoL preferences. CLINICAL IMPLICATIONS: Because personal values do influence EOL preferences, care should be taken to ascertain patient values when presenting diagnoses, prognoses, and treatment options. In particular, patients and families of patients with progressive neurological diseases will likely face a time when the patient cannot self-represent EOL wishes. Early discussion of values and preferences, particularly in the context of cognitive disease is vital to assure patient-directed care.

Transforming Care to Evidence-Based Practice With Scripted Messages: An Improvement Project for Pain Management in Outpatient Surgical Patients.

BACKGROUND: Outpatient surgeries are common and most patients experience pain postoperatively requiring nursing attention to pain management. Scripting, recommended for consistent, targeted communication to improve patient satisfaction, has limited evidence to support its use. AIMS: To explore the effect of scripted messages on self-reported pain control and patient satisfaction with care in outpatient surgical patients. METHODS: A retrospective medical record review pre- and postintervention evaluated a pain management scripted message delivered at two time points (preoperatively and postoperatively). Intention to treat analysis compared patient reports of pain control and patient satisfaction with care 48 hours postdischarge from outpatient surgical procedures. RESULTS: A total of 231 records (98 preintervention; 133 postintervention) were analyzed. The sample included 144 (62%) male, 156 (68%) married with mean age of 57.6 (SD = 16.1) years. The majority (90%) received general anesthesia, and the most common surgical procedures were urologic (24%), colorectal (17%), and laparoscopy (13%). A Mann-Whitney U test indicated patient reported pain control was statistically significantly greater for the postintervention group (mean rank = 62.66) compared to the preintervention group (mean rank = 51.95), U = 1,258, p = .01 with an effect size φ = .223. LINKING EVIDENCE TO ACTION: A scripted message showed statistical significance and a small clinical effect in pain control that adds to the body of knowledge around the effectiveness of scripting delivered by nurses. Although it is encouraging that even the small dose of scripting had a significant effect on postoperative pain control, the feasibility issues around similar study designs will require considerable resources to surmount. Practice change is a complex process requiring sensitivity to work and patient flow especially in specialty care units. Resistance to change when evidence is not robust may be especially difficult related to scripting, often perceived as a mandated intrusion into the nurse-patient relationship.

The Influence of Hypothetical Death Scenarios on Multidimensional End-of-Life Care Preferences.

BACKGROUND: Differences in end-of-life (EOL) care preferences (eg, location of death, use of life-sustaining treatments, openness to hastening death, etc) based on hypothetical death scenarios and associated physical and/or cognitive losses have yet to be investigated within the palliative care literature. AIM: The purpose of this study was to explore the multidimensional EOL care preferences in relation to 3 different hypothetical death scenarios: pancreatic cancer (acute death), Alzheimer disease (gradual death), and congestive heart failure (intermittent death). DESIGN: General linear mixed-effects regression models estimated whether multidimensional EOL preferences differed under each of the hypothetical death scenarios; all models controlled for personal experience and familiarity with the disease, presence of an advance directive, religiosity, health-related quality of life, and relevant demographic characteristics. SETTING/PARTICIPANTS: A national sample of healthy adults aged 50 years and older (N = 517) completed electronic surveys detailing their multidimensional preferences for EOL care for each hypothetical death scenario. RESULTS: The average age of the participants was 60.1 years (standard deviation = 7.6), 74.7% were female, and 66.1% had a college or postgraduate degree. Results revealed significant differences in multidimensional care preferences between hypothetical death scenarios related to preferences for location of death (ie, home vs medical facility) and preferences for life-prolonging treatment options. Significant covariates of participants' multidimensional EOL care preferences included age, sex, health-related quality of life, and religiosity. CONCLUSION: Our hypothesis that multidimensional EOL care preferences would differ based on hypothetical death scenarios was partially supported and suggests the need for disease-specific EOL care discussions.

Mercury Toxicity and Contamination of Households from the Use of Skin Creams Adulterated with Mercurous Chloride (Calomel).

Inorganic mercury, in the form of mercurous chloride, or calomel, is intentionally added to some cosmetic products sold through informal channels in Mexico and the US for skin lightening and acne treatment. These products have led to multiple cases of mercury poisoning but few investigations have addressed the contamination of cream users' homes. We report on several cases of mercury poisoning among three Mexican-American families in California from use of mercury-containing skin creams. Each case resulted in widespread household contamination and secondary contamination of family members. Urine mercury levels in cream users ranged from 37 to 482 µg/g creatinine and in non-users from non-detectable to 107 µg/g creatinine. Air concentrations of up to 8 µg/m³ of mercury within homes exceeded the USEPA/ATSDR health-based guidance and action level of <1.0 µg/m³. Mercury contamination of cream users' homes presented a multi-pathway exposure environment to residents. Homes required extensive decontamination, including disposal of most household items, to achieve acceptable air levels. The acceptable air levels used were not designed to consider multi-pathway exposure scenarios. These findings support that the calomel is able to change valence form to elemental mercury and volatilize once exposed to the skin or surfaces in the indoor environment.

Breaking the Bank: Three Financing Models for Addressing the Drug Innovation Cost Crisis.

BACKGROUND: The introduction of innovative specialty pharmaceuticals with high prices has renewed efforts by public and private healthcare payers to constrain their utilization, increase patient cost-sharing, and compel government intervention on pricing. These efforts, although rational for individual payers, have the potential to undermine the public health impact and overall economic value of these innovations for society. The emerging archetypal example is the outcry over the cost of sofosbuvir, a drug proved to cure hepatitis C infection at a cost of $84,000 per person for a course of treatment (or $1000 per tablet). This represents a radical medical breakthrough for public health, with great promise for the long-term costs associated with this disease, but with major short-term cost implications for the budgets of healthcare payers. OBJECTIVES: To propose potential financing models to provide a workable and lasting solution that directly addresses the misalignment of incentives between healthcare payers confronted with the high upfront costs of innovative specialty drugs and the rest of the US healthcare system, and to articulate these in the context of the historic struggle over paying for innovation. DISCUSSION: We describe 3 innovative financing models to manage expensive specialty drugs that will significantly reduce the direct, immediate cost burden of these drugs to public and private healthcare payers. The 3 financing models include high-cost drug mortgages, high-cost drugs reinsurance, and high-cost drug patient rebates. These models have been proved successful in other areas and should be adopted into healthcare to mitigate the high-cost of specialty drugs. We discuss the distribution of this burden over time and across the healthcare system, and we match the financial burden of medical innovations to the healthcare stakeholders who capture their overall value. All 3 models work within or replicate the current healthcare marketplace mechanisms for distributing immediate high-cost events across multiple at-risk stakeholders, and/or encouraging active participation by patients as consumers. CONCLUSION: The adoption of these 3 models for the financing of high-cost drugs would ameliorate decades-long economic conflict in the healthcare system over the value of, and financial responsibility for, drug innovation.

Synchronization of coverage, benefits, and payment to drive innovation.

More than 35% of Medicare beneficiaries receive care from providers operating under some form of shared savings/risk type of pay-for-performance incentive. Implementation of payment reform without a corresponding change to coverage, benefit, and other payment requirements, however, creates conflicting incentives that may nullify the intended aim of payment reform: to improve health outcomes, while saving costs. If related policies do not evolve to align with payment reform, those entities contracted to receive new bundled payments, such as hospitals or physician groups, will only be able to redesign care to the extent that care meets the myriad of related payment policy requirements. Shifting greater medical management authority from payers to entities managing the payment bundles is a gradual process, as the experience of commercial payers proves. Transitioning the responsibility for modifying coverage, benefit, and payment requirements from CMS to principal accountable bundlers (PABs) will depend on the PAB's degree of financial risk sharing as well as scope of the episode.

Private health plans perspectives: electronic personal health records and electronic prescribing.

BACKGROUND: Patients, payers, public health researchers, medical economists, and policymakers have all called for aggressive deployment of information technologies to support the management of health records and prescriptions. In response, payers of all types have been making investments in electronic systems. OBJECTIVES: To understand, analyze, and quantify current private payer involvement in electronic personal health records and electronic prescribing development and implementation. METHODS: A web-based survey involving 62 private commercial payer respondents representing more than 80 million covered lives and 16 national plans. RESULTS: Responses showed relatively high rates of implementation of electronic personal health records among respondents (20 currently and 9 in the next 24 months), but a unanimity of agreement of disappointing plan members' utilization of these systems. Implementation rates of electronic prescribing systems are even higher. More than half of the respondents reported utilization rates below 10%. CONCLUSION: The disappointing results with the implementations of electronic systems are most likely the result of variables exogenous to the technologies themselves. The low utilization of electronic prescribing is most likely related to the general lack of penetration of information technology into the work flow of most prescriber offices.