Evaluation of self-measured blood pressure monitoring in a southern rural West Virginia health system.

INTRODUCTION: At the time of the 2021 Behavioral Risk Factor Surveillance System survey, an estimated 32.3% of adults in the US and nearly half (43.4%, 776 000) of adults in West Virginia (WV) had hypertension. Further, the Interactive Atlas of Heart Disease and Stroke estimates an increase in the percentage of adults with hypertension in the US from 32.3% to 47.0%, with hypertension rates in WV rising as high as 58.7%, indicating a significant public health concern in the community. Hypertension increases the risk of several negative health outcomes, including heart disease and stroke, and leads to increased economic and chronic disease burden. Although certain unmodifiable factors (sex, age, race, ethnicity, and family history) increase the risk of developing hypertension, a healthy lifestyle - including a nutritious diet, maintaining a healthy weight, avoiding nicotine products, and participating in regular moderate physical activity - can decrease the risk of developing hypertension. Self-measured blood pressure (SMBP) monitoring, or home BP monitoring, when integrated with a provider's clinical management approach, is linked to improvements in BP management and control. This study represents a mid-point assessment of a remote SMBP monitoring program implemented by Cabin Creek Health Systems (CCHS), a federally qualified health center, and its impact on BP control. METHODS: CCHS implemented SMBP programming in March 2020 as one element of a developing comprehensive program aimed at reducing uncontrolled hypertension, and therefore chronic disease burden, in its service area and patient population. The project, funded by the Health Resources and Services Administration, continued to February 2023. This report represents a mid-point analysis and was based on the retrospective analysis of de-identified data collected for 234 patients to June 2022, who were assessed for changes in BP between the date of enrollment and the most recently available BP measurement. Patients were enrolled in the SMBP program if they exhibited current or previous indicators of uncontrolled hypertension (systolic ≥140 mmHg and/or diastolic ≥90 mmHg), at the discretion of their provider, and were equipped with an iBloodPressure cellular connected home BP monitoring system, manufactured by Smart Meter. Their BP readings were documented in the integration software TimeDoc Health and electronic health record athenahealth. RESULTS: At the time of enrollment, 201 (86.0%) patients had uncontrolled hypertension, with 116 (49.6%) patients having both uncontrolled systolic (≥140 mmHg) and diastolic (≥90 mmHg) values. At follow-up, the number of patients with uncontrolled hypertension decreased from 201 to 98 (41.9%), with only 36 (15.4%) patients having both uncontrolled systolic and diastolic values. Additionally, 26 (11.1%) patients were in hypertensive crisis at the time of enrollment, and no patients remained in crisis at the time of follow-up. The number of patients with BP values in the controlled range (systolic <140 mmHg and diastolic <90 mmHg) increased from 33 (14.1%) at enrollment to 136 (58.1%) at follow-up. Overall, there was a 44.0% increase in the number of patients with BP values in the controlled range at follow-up, and a concomitant 44.1% decrease in the number of patients in the uncontrolled range. These observations were consistent across multiple demographic indicators, including clinic location, three-digit zip code, and patient sex. CONCLUSION: Systematic implementation of remote BP monitoring, when integrated into clinician workflows, was associated with a substantial reduction in the number of patients with uncontrolled hypertension in this rural federally qualified health center. Further, CCHS was successful in implementing a remote SMBP monitoring program in a community challenged with transportation insecurity, and poor cellular and broadband access, of which lessons learned are applicable to other health systems interested in pursuing comparable efforts.

Fifty Years With a Brooke Ileostomy: An Autobiographical Case Report.

Permanent Brooke ileostomy continues to be a treatment option for selected patients with inflammatory bowel disease and cancer. This case report describes the author's 50-year experience living with Crohn's disease and a Brooke ileostomy, including the psychosocial and dietary adaptations required and the management of common complications such as peri-stomal irritant dermatitis, food blockage, and acute infectious diarrhea. Cross-sectional studies indicate that the quality of life with an ileostomy is usually good, but adaptation to an ileostomy is a life-long process.

Relational interventions for organizational learning: An experience report.

INTRODUCTION: Quality improvement and implementation science practitioners identify relational issues as important obstacles to success. Relational interventions may be important for successful performance improvement and fostering Learning Health Systems. METHODS: This case report describes the experience and lessons learned from implementing a relational approach to organizational change, informed by Relational Coordination Theory, in a health system. Structured interviews were used to obtain qualitative participant feedback. Relational Coordination was measured serially using a validated seven-item survey. RESULTS: An initial, relational intervention on one unit promoted increased participant engagement, self-efficacy, and motivation that led to the spontaneous, emergent dissemination of relational change, and learning into other parts of the health system. Staff involved in the intervention reported increased systems thinking, enhanced focus on communication and relationships as key drivers for improvement and learning, and greater awareness of organizational change as something co-created by staff and executives. CONCLUSIONS: This experience supports the hypothesis that relational interventions are important for fostering the development of Learning Health Systems.

Clinical Encounters and Treatment Initiation for Chronic Hepatitis C Patients: Applications of Adaptive Leadership Framework for Chronic Illness.

Chronic Hepatitis C (CHC) is the most common blood-borne infection in the U. S. Patients with CHC undergoing treatment face many challenges including adherence to medications and management of symptoms; health care practitioners are well positioned to facilitate patients' ability to address these challenges. We used the Adaptive Leadership for Chronic Illness Framework to investigate the difficulties inherent in affecting behavior change in patients undergoing treatment. We enrolled 11 patient participants and 10 provider participants. We used data from the first clinical encounter between patients and providers during which treatment was discussed. We found examples of adaptive leadership and categorized these behaviors into three themes: support for medication, coping with family/ home life, and strategizing to manage employment. We also saw examples of what we termed missed opportunities for adaptive leadership. This study illustrates the contributions of adaptive leadership behaviors by healthcare providers and the potential risk to patients in their absence.

A Health Plan's Formulary Led To Reduced Use Of Extended-Release Opioids But Did Not Lower Overall Opioid Use.

Many insurers are using formulary design to influence opioid prescribing, but it is unclear if these changes lead to reduced use or just substitution between opioids. We evaluated the effect of a new prior authorization process implemented in July 2015 for extended-release (ER) oxycodone by Blue Shield of California. Compared to other commercially insured Californians, among 880,000 Blue Shield enrollees, there was a 36 percent drop in monthly rates of ER opioid initiation relative to control-group members, driven entirely by decreases in ER oxycodone initiation and without any substitution toward other ER opioids. This reduction was offset by a 1.4 percent relative increase in the rate of short-acting opioid fills. There was no significant change in the overall use of any opioids prescribed, measured as morphine milligram equivalents. This suggests that though insurers can play a meaningful role in reducing the prescribing of high-risk ER opioids, a formulary change focused on ER opioids alone is insufficient to decrease total opioid prescribing.

Self-Reported California Hospital Palliative Care Program Composition, Certification, and Staffing Level Are Associated with Lower End-of-Life Medicare Utilization.

BACKGROUND: California hospitals report palliative care (PC) program characteristics to the California Office of Statewide Health Planning and Development (OSHPD), but the significance of this information is unknown. OBJECTIVE: Our objective was to determine whether self-reported California hospital PC program characteristics are associated with lower end-of-life (EoL) Medicare utilization. DESIGN: We performed a cross-sectional study of hospitals submitting 2012 data to OSHPD and included in the 2012 Dartmouth Atlas of Healthcare (DAHC) dataset, using statistical hypothesis testing, multivariate regression, and fuzzy set qualitative comparative analysis. SETTING/SUBJECTS: Our analysis included 203 hospitals primarily providing general medical-surgical (GMS) care. MEASUREMENTS: The following measures were available for each hospital: licensed GMS beds; type of control; presence of an inpatient or outpatient PC program; number of physicians, nurses, social workers, and chaplains on the PC team; number of PC-certified staff; percentage of Medicare decedents dying as inpatients; and average total hospital days, ICU days, and physician visits per Medicare decedent in the last six months of life. RESULTS: Investor-owned hospitals have fewer PC programs and higher EoL utilization than do nonprofit hospitals. Among nonprofit hospitals, small size (substantially fewer than 150 medical-surgical beds), or large size and having an inpatient PC program with more than three PC staff per 100 GMS beds, or an interdisciplinary PC-certified team, is associated with significantly lower EoL hospital utilization and percentage of deaths occurring in the inpatient setting. DISCUSSION: Improved program performance associated with higher staffing levels may be mediated by increased access to and earlier PC interventions. CONCLUSION: California hospital-reported PC program characteristics are associated with significantly lower inpatient utilization by Medicare decedents.

Adaptive leadership framework for chronic illness: framing a research agenda for transforming care delivery.

We propose the Adaptive Leadership Framework for Chronic Illness as a novel framework for conceptualizing, studying, and providing care. This framework is an application of the Adaptive Leadership Framework developed by Heifetz and colleagues for business. Our framework views health care as a complex adaptive system and addresses the intersection at which people with chronic illness interface with the care system. We shift focus from symptoms to symptoms and the challenges they pose for patients/families. We describe how providers and patients/families might collaborate to create shared meaning of symptoms and challenges to coproduce appropriate approaches to care.

Physician organization care management capabilities associated with effective inpatient utilization management: a fuzzy set qualitative comparative analysis.

BACKGROUND: We studied the relationship between physician organization (PO) care management capabilities and inpatient utilization in order to identify PO characteristics or capabilities associated with low inpatient bed-days per thousand. METHODS: We used fuzzy-set qualitative comparative analysis (fsQCA) to conduct an exploratory comparative case series study. Data about PO capabilities were collected using structured interviews with medical directors at fourteen California POs that are delegated to provide inpatient utilization management (UM) for HMO members of a California health plan. Health plan acute hospital claims from 2011 were extracted from a reporting data warehouse and used to calculate inpatient utilization statistics. Supplementary analyses were conducted using Fisher's Exact Test and Student's T-test. RESULTS: POs with low inpatient bed-days per thousand minimized length of stay and surgical admissions by actively engaging in concurrent review, discharge planning, and surgical prior authorization, and by contracting directly with hospitalists to provide UM-related services. Disease and case management were associated with lower medical admissions and readmissions, respectively, but not lower bed-days per thousand. CONCLUSIONS: Care management methods focused on managing length of stay and elective surgical admissions are associated with low bed-days per thousand in high-risk California POs delegated for inpatient UM. Reducing medical admissions alone is insufficient to achieve low bed-days per thousand. California POs with high bed-days per thousand are not applying care management best practices.

The Heart of New Ulm Project: using community-based cardiometabolic risk factor screenings in a rural population health improvement initiative.

Awareness of cardiovascular disease and diabetes risk factors can improve the health of individuals and populations. Community-based risk factor screening programs may be particularly useful for quantifying the burden of cardiometabolic risk in a given population, particularly in underserved areas. This study provided a description of a screening platform and how it has been used to monitor the cardiometabolic risk profile within the broader Heart of New Ulm Project, which is based in a rural Minnesota community. A cross-sectional, descriptive examination of baseline screening data indicated that 45% of the target population participated in the program over 8 months. Overall, 13% of the sample reported a personal history of diabetes or cardiovascular disease. Among the subset without active cardiometabolic disease, 35% were found to be at high risk for developing cardiovascular disease or type 2 diabetes over the next 8-10 years. A high prevalence of metabolic syndrome, high low-density lipoprotein cholesterol, obesity, and low fruit/vegetable consumption were of particular concern in this community. This article describes the use of screening results to inform the design of intervention programs that target these risk factors at both the community and individual levels. In addition, design considerations for future community-based cardiometabolic risk factor screening programs are discussed, with a focus on balancing program objectives related to health surveillance, research, and the delivery of preventive health care services.

Stress and workplace productivity loss in the Heart of New Ulm project.

OBJECTIVE: The impact of stress in conjunction with lifestyle factors on workplace productivity is understudied, thus the relationship between these variables was examined. METHODS: Negative binomial regression was used to test the cross-sectional association between stress and productivity loss in a sample of 2823 adults. RESULTS: After body mass index adjustment, there was an interaction between stress and physical activity (ß ± SE = 0.002 ± 0.001, P = 0.033). Active participants with low stress had 2% estimated productivity loss, whereas active participants with high stress had more than 11% productivity loss. Other lifestyle factors were not significant. CONCLUSIONS: Higher stress generally predicted greater productivity loss, but this association varied. At low stress, more activity was associated with less productivity loss. At high stress, more activity was associated with more productivity loss, perhaps indicating that individuals cope by exercising more and working less.

Informed choice assistance for women making uterine fibroid treatment decisions: a practical clinical trial.

BACKGROUND: There is limited evidence about how to ensure that patients are helped to make informed medical care decisions. OBJECTIVE: To test a decision support intervention for uterine fibroid treatments. DESIGN AND SETTING: Practical clinical trial to test informed choice assistance in 4 randomly assigned gynecology clinics compared to 5 others providing a pamphlet. PATIENTS: Three hundred women facing a treatment decision for fibroids over a 13-month period. INTERVENTION: Mailed DVD and brochure about fibroid treatments plus the Ottawa decision guide and an offer of counseling soon after an index visit. MEASUREMENTS: Mailed survey 6 to 8 weeks later asking about knowledge, preferences, and satisfaction with decision support. RESULTS: In total, 244 surveys were completed for an adjusted response rate of 85.4%. On a 5-point scale, intervention subjects reported more treatment options being mentioned (3.0 v. 2.4), had a higher knowledge score (3.3 v. 2.8), and were more likely to report being adequately informed (4.4 v. 4.0), and their decision was both more satisfactory (4.3 v. 4.0) and more consistent with their personal values (4.5 v. 4.2). Neither knowledge nor use of the intervention was associated with greater concordance between preferences and decisions. LIMITATIONS: Implementation of intervention may not have been well timed to the decision for some patients, limiting their use of the materials and counseling. CONCLUSION: It is difficult to integrate structured decision support consistently into practice. Decision support for benign uterine conditions showed effects on knowledge and satisfaction but not on concordance.

Comparing costs and quality of care at retail clinics with that of other medical settings for 3 common illnesses.

BACKGROUND: Retail clinics are an increasingly popular source for medical care. Concerns have been raised about the effect of these clinics on the cost, quality, and delivery of preventive care. OBJECTIVE: To compare the care received at retail clinics for 3 acute conditions with that received at other care settings. DESIGN: Claims data from 2005 and 2006 from the health plan were aggregated into care episodes (units that included initial and follow-up visits, pharmaceuticals, and ancillary tests). After 2100 episodes (700 each) were identified in which otitis media, pharyngitis, and urinary tract infection (UTI) were treated first in retail clinics, these episodes were matched with other episodes in which these illnesses were treated first in physician offices, urgent care centers, or emergency departments. SETTING: Enrollees of a large Minnesota health plan. PATIENTS: Enrollees who received care for otitis media, pharyngitis, or UTI. MEASUREMENTS: Costs per episode, performance on 14 quality indicators, and receipt of 7 preventive care services at the initial appointment or subsequent 3 months. RESULTS: Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P < 0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and 13.7%) (P > 0.05 vs. retail clinics). In emergency departments, average prescription costs were higher and aggregate quality scores were significantly lower than in other settings. LIMITATIONS: A limited number of quality measures and preventive care services were studied. Despite matching, patients at different care sites might differ in their severity of illness. CONCLUSION: Retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care. PRIMARY FUNDING SOURCE: California HealthCare Foundation.

Evaluating preference-sensitive care for uterine fibroids: it's not so simple.

BACKGROUND: Preference-sensitive care decisions should reflect an informed patient's preferences. This retrospective survey of women with fibroids, a benign condition with multiple treatment options, sought to evaluate the extent to which this was measurable and true. METHODS: All 260 women in one medical group with visit codes for uterine fibroids during a 9-month period in 2006 were mailed surveys constructed through focus groups with physicians and interviews with patients. Correlations tested associations among their preferences, knowledge, and treatment decisions. RESULTS: The adjusted response rate was 82%, but only 100 respondents fit all criteria for analysis. Nearly all wanted to either share or control the decision, and 86% felt informed, satisfied, and that the decision was consistent with their values. However, only 55% of patients could answer at least five of seven fibroid questions correctly. Hysterectomy use was significantly correlated with desire to relieve symptoms, have a permanent treatment, and do something right away (r = 0.36, 0.37, and 0.30, respectively). Those deciding not to treat were significantly less likely to have these preferences (r = -0.65, -0.40, and -0.58). These relationships were not affected by patient knowledge level, but patients with high knowledge scores were significantly more likely to believe their decision was concordant with their preferences (94.9% vs. 74.4%, p < 0.01). CONCLUSIONS: There were knowledge gaps but unclear associations between knowledge and decision-preference relationships for this condition, which has many different treatment alternatives. A prospective intervention trial is needed to determine if better information and counseling would produce stronger concordance between treatment selected and patient preferences.