A qualitative study of clinic and community member perspectives on intervention toolkits: "Unless the toolkit is used it won't help solve the problem".

BACKGROUND: Intervention toolkits are common products of grant-funded research in public health and primary care settings. Toolkits are designed to address the knowledge translation gap by speeding implementation and dissemination of research into practice. However, few studies describe characteristics of effective intervention toolkits and their implementation. Therefore, we conducted this study to explore what clinic and community-based users want in intervention toolkits and to identify the factors that support application in practice. METHODS: In this qualitative descriptive study we conducted focus groups and interviews with a purposive sample of community health coalition members, public health experts, and primary care professionals between November 2010 and January 2012. The transdisciplinary research team used thematic analysis to identify themes and a cross-case comparative analysis to explore variation by participant role and toolkit experience. RESULTS: Ninety six participants representing primary care (n = 54, 56%) and community settings (n = 42, 44%) participated in 18 sessions (13 focus groups, five key informant interviews). Participants ranged from those naïve through expert in toolkit development; many reported limited application of toolkits in actual practice. Participants wanted toolkits targeted at the right audience and demonstrated to be effective. Well organized toolkits, often with a quick start guide, with tools that were easy to tailor and apply were desired. Irrespective of perceived quality, participants experienced with practice change emphasized that leadership, staff buy-in, and facilitative support was essential for intervention toolkits to be translated into changes in clinic or public -health practice. CONCLUSIONS: Given the emphasis on toolkits in supporting implementation and dissemination of research and clinical guidelines, studies are warranted to determine when and how toolkits are used. Funders, policy makers, researchers, and leaders in primary care and public health are encouraged to allocate resources to foster both toolkit development and implementation. Support, through practice facilitation and organizational leadership, are critical for translating knowledge from intervention toolkits into practice.

Milk Options Observation (MOO): A Mixed-Methods Study of Chocolate Milk Removal on Beverage Consumption and Student/Staff Behaviors in a Rural Elementary School.

Providing flavored milk in school lunches is controversial, with conflicting evidence on its impact on nutritional intake versus added sugar consumption and excess weight gain. Nonindustry-sponsored studies using individual-level analyses are needed. Therefore, we conducted this mixed-methods study of flavored milk removal at a rural primary school between May and June 2012. We measured beverage selection/consumption pre- and post-chocolate milk removal and collected observation field notes. We used linear and logistic mixed models to assess beverage waste and identified themes in staff and student reactions. Our analysis of data from 315 unique students and 1,820 beverages choices indicated that average added sugar intake decreased by 2.8 g postremoval, while average reductions in calcium and protein consumption were negligible (12.2 mg and 0.3 g, respectively). Five thematic findings emerged, including concerns expressed by adult staff about student rebellion following removal, which did not come to fruition. Removing flavored milk from school-provided lunches may lower students' daily added sugar consumption without considerably decreasing calcium and protein intake and may promote healthy weight.

The financial impact of team-based care on primary care.

OBJECTIVES: Although team-based care can improve coronary heart disease (CHD) risk factors and is considered cost-effective from a healthcare system perspective, little is known about the financial impact of team-based primary care for secondary prevention of CHD. The purpose of this study was to define the impact of team-based care for CHD on utilization, costs, and revenue of a private primary care practice. STUDY DESIGN: Interrupted time series analysis. METHODS: Between March 1, 2010, and March 31, 2013, we assisted a private medical practice, comprising 5 primary care clinic sites, to organize and deliver team-based care for patients with CHD. We used billing records and the registered nurse care manager's diary to calculate the cost of team-based care, differences in the average number of visits per patient, and revenue per patient before and after the implementation of team-based care. RESULTS: The net cost of team-based primary care was $291 per patient over the 1-year period of observation. CONCLUSIONS: The findings from this study are consistent with other economic analyses of team-based care and suggest that payment for care must be restructured if patients are expected to enjoy the benefits of team-based primary care.

Using Principles of Complex Adaptive Systems to Implement Secondary Prevention of Coronary Heart Disease in Primary Care.

CONTEXT: Primary care practice. OBJECTIVE: To test whether the principles of complex adaptive systems are applicable to implementation of team-based primary care. DESIGN: We used complex adaptive system principles to implement team-based care in a private, five-clinic primary care practice. We compared randomly selected samples of patients with coronary heart disease (CHD) and diabetes before system implementation (March 1, 2009, to February 28, 2010) and after system implementation (December 1, 2011, to March 31, 2013). MAIN OUTCOME MEASURES: Rates of patients meeting the composite goals for CHD (blood pressure < 140/90 mmHg, low-density lipoprotein cholesterol level < 100 mg/dL, tobacco-free, and using aspirin unless contraindicated) and diabetes (CHD goal plus hemoglobin A1c concentration < 8%) before and after the intervention. We also measured provider and patient satisfaction with preventive services. RESULTS: The proportion of patients with CHD who met the composite goal increased from 40.3% to 59.9% (p < 0.0001) because documented aspirin use increased (65.2%-97.5%, p < 0.0001) and attainment of the cholesterol goal increased (77.0%-83.9%, p = 0.0041). The proportion of diabetic patients meeting the composite goal rose from 24.5% to 45.4% (p < 0.0001) because aspirin use increased (58.6%-97.6%, p < 0.0001). Increased percentages of patients meeting the CHD and diabetes composite goals were not significantly different (p = 0.2319). Provider satisfaction with preventive services delivery increased significantly (p = 0.0017). Patient satisfaction improved but not significantly. CONCLUSION: Principles of complex adaptive systems can be used to implement team-based care systems for patients with CHD and possibly diabetic patients.

A qualitative study of processes used to implement evidence-based care in a primary care practice.

BACKGROUND: Evidence-based guidelines for care of coronary heart disease patients are not fully implemented. Primary care practices provide most of the care for these patients. OBJECTIVE: To learn how providers and staff in a busy primary care practice implement interventions to provide evidence-based care of coronary heart disease patients. METHODS: We conducted a qualitative analysis of the responses to open-ended questions in nine electronically administered bimonthly surveys of key physicians, clinic staff and managers in the practice. RESULTS: Ten to 16 (mean=12.3) personnel responded to each survey. Nearly 30% were physicians and 40.5% were clinic staff. Four major themes emerged from the qualitative analysis: (i) giving data about not-at-goal patients to providers for care plan development; (ii) developing team roles and defining tasks; (iii) providing patient care and implementing care plans and (iv) providing technology support to generate useful, accurate data. The frequency that the subthemes were mentioned varied from survey to survey, but their mention persisted over the entire time of all nine surveys. CONCLUSIONS: Developing a system for implementing evidence-based care involves considerations of roles and teamwork, technology use to develop a patient registry and obtain needed clinical data, care processes for pre-visit planning, and between-visit care management. A registered nurse care manager is a central figure in implementing and sustaining the process. Implementing evidence-based guidelines is an ongoing process of revision, retraining and reinforcement.

Calorie labeling in a rural middle school influences food selection: findings from community-based participatory research.

BACKGROUND: Calorie labeling at the point-of-purchase in chain restaurants has been shown to reduce energy intake. OBJECTIVE: To investigate the impact of point-of-purchase calorie information at one rural middle school. METHODS: With a community-based participatory research framework a mixed method approach was used to evaluate the impact of point-of-purchase calorie information. Students in grades 6-8, dining at the school cafeteria January and February 2010, participated for 17 school days each month; in January a menu was offered in the usual manner without calorie labels; the same menu was prepared in February with the addition of calorie labels at point-of-purchase. Gross calories served per student were measured each day allowing for matched comparison by menu. In March/April of 2010, 32 students who ate in the cafeteria 3 or more times per week were interviewed regarding their views on menu labeling. RESULTS: Calorie consumption decreased by an average of 47 calories/day; fat intake reduced by 2.1 grams/day. Five main themes were consistent throughout the interviews. CONCLUSION: Point-of-purchase calorie labels can play a role in reducing the number of calories consumed by middle school age children at the lunch. The majority of students interviewed found the calorie labels helped them choose healthier food.

Engaging the underserved: a process model to mobilize rural community health coalitions as partners in translational research.

PURPOSE: Community engagement (CE) and community-engaged research (CEnR) are increasingly recognized as critical elements in research translation. Process models to develop CEnR partnerships in rural and underserved communities are needed. METHOD: Academic partners transformed four established Community Health Improvement Partnerships (CHIPs) into Community Health Improvement and Research Partnerships (CHIRPs). The intervention consisted of three elements: an academic-community kickoff/orientation meeting, delivery of eight research training modules to CHIRP members, and local community-based participatory research (CBPR) pilot studies addressing childhood obesity. We conducted a mixed methods analysis of pre-/postsurveys, interviews, session evaluations, observational field notes, and attendance logs to evaluate intervention effectiveness and acceptability. RESULTS: Forty-nine community members participated; most (78.7%) attended five or more research training sessions. Session quality and usefulness was high. Community members reported significant increases in their confidence for participating in all phases of research (e.g., formulating research questions, selecting research methods, writing manuscripts). All CHIRP groups successfully conducted CBPR pilot studies. CONCLUSIONS: The CHIRP process builds on existing infrastructure in academic and community settings to foster CEnR. Brief research training and pilot studies around community-identified health needs can enhance individual and organizational capacity to address health disparities in rural and underserved communities.

Elementary school children's recess schedule and dietary intake at lunch: a community-based participatory research partnership pilot study.

BACKGROUND: School recess before lunch (e.g., reverse recess) has been suggested as a means to improve dietary intake and classroom behavior but limited research explores this school-based policy. This pilot study tests the impact of recess scheduling on dietary intake at school lunch. METHODS: A mixed methods approach included assessment of dietary intake assessed by measured plate waste on five non-consecutive days at Madras Elementary School, Madras, Oregon, United States (n = 104 intervention; 157 controls). Subjects included primary school children in grades kindergarten, first and second. Logistic regression was used to test associations between recess timing and dietary intake. Four focus groups involving teachers and staff explored reactions to the intervention. Qualitative data was transcribed verbatim and assessed for key themes. RESULTS: Milk consumption was 1.3 oz greater in the intervention group (5.7 oz vs. 4.4 oz); and 20% more of the intervention participants drank the entire carton of milk (42% vs. 25%, p < 0.0001). Intervention participants were 1.5 times more likely to meet the nutritional guidelines for calcium (≥267 mg, p = 0.01) and fat (≤30% of total energy, p = 0.02). Consumption of entrees, vegetables, and fruits did not differ between groups. Teachers perceived recess before lunch beneficial to classroom behavior and readiness to concentrate following lunch. CONCLUSIONS: The recess before lunch intervention yielded increased milk consumption; the nutritional and social benefits observed warrant policy change consideration. Future research should assess the impact of recess before lunch in larger districts.

Rural Oregon community perspectives: introducing community-based participatory research into a community health coalition.

The Community Health Improvement Partnership (CHIP) model has supported community health development in more than 100 communities nationally. In 2011, four rural Oregon CHIPs collaborated with investigators from the Oregon Rural Practice-based Research Network (ORPRN), a component of the Oregon Clinical and Translational Research Institute (OCTRI), to obtain training on research methods, develop and implement pilot research studies on childhood obesity, and explore matches with academic partners. This article summarizes the experiences of the Lincoln County CHIP, established in 2003, as it transitioned from CHIP to Community Health Improvement and Research Partnership (CHIRP). Our story and lessons learned may inform rural community-based health coalitions and academicians who are engaged in or considering Community-based participatory research (CBPR) partnerships. Utilizing existing infrastructure and relationships in community and academic settings provides an ideal starting point for rural, bidirectional research partnerships.

Prioritizing research needs based on a systematic evidence review: a pilot process for engaging stakeholders.

BACKGROUND/CONTEXT: Systematic evidence reviews (SERs) identify knowledge gaps in the literature, a logical starting place for prioritizing future research. Varied methods have been used to elicit diverse stakeholders' input in such prioritization. OBJECTIVE: To pilot a simple, easily replicable process for simultaneously soliciting consumer, clinician and researcher input in the identification of research priorities, based on the results of the 2009 SER on screening adults for depression in primary care. METHODS: We recruited 20 clinicians, clinic staff, researchers and patient advocates to participate in a half-day event in October 2009. We presented SER research methods and the results of the 2009 SER. Participants took part in focus groups, organized by profession; broad themes from these groups were then prioritized in a formal exercise. The focus group content was also subsequently analysed for specific themes. RESULTS: Focus group themes generally reacted to the evidence presented; few were articulated as research questions. Themes included the need for resources to respond to positive depression screens, the impact of depression screening on delivery systems, concerns that screening tools do not address comorbid or situational causes of depression and a perceived 'disconnect' between screening and treatment. The two highest-priority themes were the system effects of screening for depression and whether depression screening effectively leads to improved treatment. CONCLUSION: We successfully piloted a simple, half-day, easily replicable multi-stakeholder engagement process based on the results of a recent SER. We recommend a number of potential improvements in future endeavours to replicate this process.

Turning on the care coordination switch in rural primary care: voices from the practices--clinician champions, clinician partners, administrators, and nurse care managers.

This study sought to understand the acceptability and feasibility of office-based nurse care management in medium to large rural primary care practices. A qualitative assessment of Care Management Plus (a focused medical home model for complex patients) implementation was conducted using semistructured interviews with 4 staff cohorts. Cohorts included clinician champions, clinician partners, practice administrators, and nurse care managers. Seven key implementation attributes were: a proven care coordination program; adequate staffing; practice buy-in; adequate time; measurement; practice facilitation; and functional information technology. Although staff was positive about the care coordination concept, model acceptability was varied and additional study is required to determine sustainability.

Unmet dental needs in rural primary care: a clinic-, community-, and practice-based research network collaborative.

BACKGROUND: Oral health is an essential component of general health and well-being, yet barriers to the access of dental care and unmet needs are pronounced, particularly in rural areas. Despite associations with systemic health, few studies have assessed unmet dental needs across the lifespan as they present in primary care. This study describes the prevalence of oral health conditions and unmet dental needs among patients presenting for routine care in a rural Oregon family medicine practice. METHODS: Eight primary care clinicians were trained to conduct basic oral health screenings for 7 dental conditions associated with International Statistical Classification of Diseases and Related Health Problems 9-Clinical Modification codes. During the 6-week study period, patients older than 12 months of age who presented to the practice for a regularly scheduled appointment received the screening and completed a brief dental access survey. RESULTS: Of 1655 eligible patients, 40.7% (n = 674) received the screening and 66.9% (n = 1108) completed the survey. Half of the patients who were screened (46.0%, n = 310) had oral health conditions detected, including partial edentulism (24.5%), dental caries (12.9%), complete edentulism (9.9%), and cracked teeth (8.9%). Twenty-eight percent of the patients reported experiencing unmet dental needs. Patients with dental insurance were significantly more likely to report better oral and general health outcomes as compared with those who had no insurance or health insurance only. CONCLUSIONS: Oral health diseases and unmet dental needs presented substantially in patients with ages ranging across the lifespan from one rural primary care practice. Primary care settings may present opportune environments for reaching patients who are unable to obtain regular dental care.

Transitioning from CHIP to CHIRP: blending community health development with community-based participatory research.

In 2006, a community health development model was used to engage citizens in Jefferson County, Oregon, around local health concerns. Childhood obesity emerged as a priority health issue. In 2007, a research component was introduced by Oregon Health & Science University to help the community garner resources and inform the field. This case study describes the collaboration between the Mountain View Community Health Improvement Partnership and Oregon Health & Science University to increase the number of county children at a healthy weight. Research and projects occurred simultaneously since community members are motivated by action, and research is a slower process.

Community characteristics affecting emergency department use by Medicaid enrollees.

OBJECTIVES: In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. METHODS: This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. RESULTS: ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. CONCLUSIONS: Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

A web based video tool for MR arthrography.

OBJECTIVE: Our objective was to integrate digital video and web technology to construct a useful self paced learning tool to deliver recorded techniques of magnetic resonance (MR) arthrography for junior radiology residents and medical students. CONCLUSION: The streaming of audio media, an emerging technology, is an effective vehicle to deliver educational material over the Internet using commercially available PCs and modems, especially when teaching resources are limited.