Implementation of Care Management: An Analysis of Recent AHRQ Research.

Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.

Has the rescheduling of hydrocodone changed ED prescribing practices?

OBJECTIVE: The objective was to examine the effect of hydrocodone-containing product (HCP) rescheduling on the proportion of prescriptions for HCPs given to patients discharged from the emergency department (ED). METHODS: Electronic queries of ED records were used to identify patients aged 15 years and older discharged with a pain-related prescription in the 12 months before and after HCP rescheduling. Prescriptions were classified as HCPs; other Schedule II medications (eg, oxycodone products); other Schedule III medications (eg, codeine products); and non-Schedule II/III products (eg, nonsteroidal anti-inflammatory drugs). We compared the proportions of patients receiving each type of prescription before and after rescheduling using χ2 analysis and used logistic regression to explore the relationship between prescription type and time period while controlling for age, sex, race, and ethnicity. RESULTS: Before rescheduling, 58.1% (95% confidence interval [CI], 57.4-58.7) of patients receiving a pain-related prescription received an HCP; after rescheduling, 13.2% (95% CI, 12.7-13.7) received an HCP (P < .001). Concurrently, other Schedule III prescriptions increased (pre: 11.7% [CI, 11.3-12.2] vs post: 44.9% [CI, 44.2-45.6], P < .001)), as did non-Schedule II/III prescriptions (pre: 51.8% [CI, 51.2-52.5] vs post: 59.3% [CI, 58.6-60.0], P < .001). When controlling for demographic characteristics, patients remained less likely to receive an HCP after rescheduling (adjusted odds ratio [AOR], 0.11; CI, 0.10-0.11) and more likely to receive other Schedule III (AOR, 6.1; CI, 5.8-6.5) and non-Schedule II/III (AOR, 1.4; CI, 1.3-1.4) products. CONCLUSION: Rescheduling HCPs from Schedule III to Schedule II led to a substantial decrease in HCP prescriptions in our ED and an increase in prescriptions for other Schedule III and non-Schedule II/III products.

Connecting the dots and merging meaning: using mixed methods to study primary care delivery transformation.

OBJECTIVE: To demonstrate the value of mixed methods in the study of practice transformation and illustrate procedures for connecting methods and for merging findings to enhance the meaning derived. DATA SOURCE/STUDY SETTING: An integrated network of university-owned, primary care practices at the University of Utah (Community Clinics or CCs). CC has adopted Care by Design, its version of the Patient Centered Medical Home. STUDY DESIGN: Convergent case study mixed methods design. DATA COLLECTION/EXTRACTION METHODS: Analysis of archival documents, internal operational reports, in-clinic observations, chart audits, surveys, semistructured interviews, focus groups, Centers for Medicare and Medicaid Services database, and the Utah All Payer Claims Database. PRINCIPAL FINDINGS: Each data source enriched our understanding of the change process and understanding of reasons that certain changes were more difficult than others both in general and for particular clinics. Mixed methods enabled generation and testing of hypotheses about change and led to a comprehensive understanding of practice change. CONCLUSIONS: Mixed methods are useful in studying practice transformation. Challenges exist but can be overcome with careful planning and persistence.

Species difference in adaptive use of public information in sticklebacks.

Animals foraging on variable food sources can refine their estimates of patch quality by monitoring the success of others (i.e. collect 'public information'). Here, we show that both three-spined sticklebacks (Gasterosteus aculeatus) and nine-spined sticklebacks (Pungitius pungitius) use past cues provided by others to locate food but only nine-spined sticklebacks use prior public information to assess patch quality, regardless of whether demonstrators were conspecifics or heterospecifics. Moreover, nine-spined but not three-spined sticklebacks preferentially hid in vegetation during the demonstration, a position from which they could observe both patches simultaneously and collect public information. We conclude that species differences in the use of public information can be explained by variations in habitat choice and response to predation. Our findings expand current understanding of the scope of public-information use in animals by showing that fishes can use public-information in a foraging context and from heterospecifics. The study suggests that public-information use is an adaptation that allows animals vulnerable to predation to acquire valuable foraging information at low risk.

Rethinking adaptation: the niche-construction perspective.

Niche construction refers to the capacity of organisms to construct, modify, and select important components of their local environments, such as nests, burrows, pupal cases, chemicals, and nutrients. A small but increasing number of evolutionary biologists regard niche construction as an evolutionary process in its own right, rather than as a mere product of natural selection. Through niche construction organisms not only influence the nature of their world, but also in part determine the selection pressures to which they and their descendants are exposed, and they do so in a non-random manner. Mathematical population genetics analyses have revealed that niche construction is likely to be evolutionarily consequential because of the feedback that it generates in the evolutionary process. A parallel movement has emerged in ecosystem ecology, where researchers stress the utility of regarding organisms as ecosystem engineers, who partly control energy and matter flows. From the niche construction standpoint, the evolving complementary match between organisms and environments is the product of reciprocal interacting processes of natural selection and niche construction. This essay reviews the arguments put forward in favor of the niche-construction perspective.