David A Haggstrom’s research while affiliated with Richard L. Roudebush VA Medical Center and other places

Background Medication reconciliation is essential for optimizing medication use. In part to promote effective medication reconciliation, the Department of Veterans Affairs (VA) invested substantial resources in health information exchange (HIE) technologies. The objectives of this qualitative study were to characterize VA clinicians’ use of HIE tools for medication reconciliation in their clinical practice and to identify facilitators and barriers. Methods We recruited inpatient and outpatient prescribers (physicians, nurse practitioners, physician assistants) and pharmacists at four geographically distinct VA medical centers for observations and interviews. Participants were observed as they interacted with HIE or medication reconciliation tools during routine work. Participants were interviewed about clinical decision-making pertaining to medication reconciliation and use of HIE tools, and about barriers and facilitators to use of the tools. Qualitative data were analyzed via inductive and deductive approaches using a priori codes. Results A total of 63 clinicians participated. Over half (58%) were female, and the mean duration of VA clinical experience was 7 (range 0–32) years. Underlying motivators for clinicians seeking data external to their VA medical center were having new patients, current patients receiving care from an external institution, and clinicians’ concerns about possible medication discrepancies among institutions. Facilitators for using HIE software were clinicians’ familiarity with the HIE software, clinicians’ belief that medication information would be available within HIE, and their confidence in the ability to find HIE medication-related data of interest quickly. Six overarching barriers to HIE software use for medication coordination included visual clutter and information overload within the HIE display; challenges with HIE interface navigation; lack of integration between HIE and other electronic health record interfaces, necessitating multiple logins and application switching; concerns with the dependability of HIE medication information; unfamiliarity with HIE tools; and a lack of HIE data from non-VA facilities. Conclusions This study is believed to be the first to qualitatively characterize clinicians’ HIE use with respect to medication reconciliation. Results inform recommendations to optimize HIE use for medication management activities. We expect that healthcare organizations and software vendors will be able to apply the findings to develop more effective and usable HIE information displays.

This Viewpoint describes the benefits and challenges of active surveillance as a clinical approach to monitor low-risk cancers with favorable prognoses.

e13799 Background: Individuals with colorectal cancer (CRC) experience persistent and disabling symptoms across the care trajectory. Consequently, Survivorship Care Plans (SCPs) have been developed to assist patients in navigating these experiences. However, there are mixed results regarding its effectiveness and implementation in helping cancer survivors. The purpose of this qualitative study is to explore and compare the attitudes of cancer specialists and PCPs on current practices for survivorship care coordination, and to identify potential barriers and facilitators to implementing a SCP-PHR tool. Methods: Semi-structured interviews were conducted with 22 providers involved in cancer care, including specialty care providers (n=16) and primary care providers (n=6). The interview guide was based upon the Consolidated Framework for Implementation Research (CFIR). The current analysis focused solely on the “tension for change” domain. Two researchers analyzed individual transcripts using a combined thematic approach (inductive and deductive) to identify common themes and important findings. Results: While multiple barriers were identified, care coordination/communication among different specialties emerged as a notable challenge. Providers indicated that a lack of well-defined responsibilities between various specialties led to challenges in providing proper follow-up care. Most providers had not routinely utilized SCPs in their practice. Several specialty care providers expressed uncertainty about who handles follow-up care (n=11; 68.7%) while others believed that PCPs or nurses should bear that responsibility (n=5; 31.2%). In contrast, many PCPs voiced that follow-up care responsibility should fall to oncologists (n= 5, 83.3%) due to provider burden and lack of familiarity with cancer symptomatology. As a result, providers noted that patients are not receiving adequate information about their care and are unaware of their treatment needs. Specialty care providers expressed concerns that areas of non-cancer symptom management and preventive care are not being adequately addressed alongside cancer-specific symptoms. Primary care providers echoed similar concerns and noted that care tools, like SCP-PHRs and warm hand-offs, could be implemented to address these concerns. Conclusions: Barriers surrounding survivorship care coordination underscore the need for creating a efficient SCP-PHRs, as providers seek support in providing care information to patients. Providers suggested a virtual platform should be structured in a concise format that delivers comprehensive information tailored to individual needs and addresses symptoms across all stages of their cancer continuum. Future studies may focus on understanding differences in perspectives among those who have actively engaged with SCPs in their care practices.

Population health in the United States continues to lag behind other wealthy nations. Primary care has the promise of enhancing population health; however, the implementation of a population health approach within primary care deserves further consideration. Clinicians and staff from a national sample of 10 innovative primary care practices participated in a working conference to reflect upon population health approaches in primary care. A series of small- and large-group discussions were recorded, transcribed, and coded through an immersion/crystallization approach. Two prominent themes emerged: (1) Transitioning to a population health focus generally develops through stages, with early implementation focusing on risk stratification and later, more advanced stages focusing on community health; and (2) Several inherent barriers confront implementation of a population health approach, including tensions with patient-centered care, and limitations of health information technology. A broader conceptualization of population health in terms of community health could more effectively allow partnerships among primary care, large health care systems, public health organizations, patients, and other partners in the community.

Background Despite guideline recommendations, our prior work revealed that more than half of low-risk bladder cancer patients within the Department of Veterans Affairs (VA) undergo too many surveillance procedures and about a third of high-risk patients do not undergo enough procedures. Thus, we developed and integrated implementation strategies to improve risk-aligned bladder cancer surveillance for the VA system. Methods In prior work we conducted an Implementation Mapping process to develop nine implementation strategies: change record systems, educational meetings, champions, tailoring, preparing patients to be active participants, external facilitation, remind clinicians, audit & feedback, and a blueprint. In this work, we integrated these strategies as improvement approaches across four VA sites. The primary outcomes were qualitatively measured implementation outcomes, including appropriateness, acceptability, feasibility, and sustainability. Exploratory outcomes were quantitatively measured and included clinicians’ recommendations for guideline-concordant bladder cancer surveillance intervals. Results Changing record systems via a template in the electronic health record (EHR) was most impactful. Educational meetings and champions were critical for the integration of the strategies. The ability to tailor strategies contributed to clinician buy-in. Preparing patients to be active participants was helpful for clinicians and patients but time-consuming. Facilitation was key to launching the strategies. Some sites used and valued clinician reminders in the form of cheat sheets and posters, but this varied across sites. For low-risk patients, clinicians recommended guideline-concordant surveillance about 65% of the time at baseline, and this improved to 70% during evaluation. Across all risk groups, recommendations for guideline-concordant surveillance intervals were already present in more than 85% of baseline encounters and did not change. All sites sustained use of the changed EHR system, while sustainability of the other strategies was variable. Conclusions In general, strategies were successfully integrated and found to be appropriate, acceptable, and feasible. Future work should assess the impact of the improvement approaches on clinical care processes, particularly on reducing overuse of surveillance procedures among low-risk patients, as our study was not designed or powered to formally assess this outcome. Trial Registration The implementation strategies were not considered a healthcare intervention on human participants by the governing funding agency and IRB. Rather, they were seen as quality improvement interventions. Thus, this study did not meet criteria for a clinical trial and was not registered as such.

The purpose of this article is to examine the association of relationship satisfaction concordance between breast cancer survivors (BCSs) and their partners with matched controls on physical and psychosocial outcomes. Dyads of BCSs, age-matched controls, and partners were recruited as part of a larger, cross-sectional QOL survey study. Relationship concordance was measured by the ENRICH marital satisfaction score, with each dyad’s score equaling the absolute value of the difference in satisfaction between survivor/control and their partner (lower score = greater concordance). Dependent variables for survivors/controls were social constraint, physical function, depression, fatigue, attention function, and sleep disturbance. Relationship satisfaction and concordance were used as the primary independent variables, while controlling for dyad category, race, education, income, and age within multiple linear regression models. The sample consisted of 387 dyads (220 BCSs, 167 controls). Relationship satisfaction concordance ranged from 0 to 53.4 (mean = 10.2). The BCS dyads had significantly worse concordance (11.1) than the controls (9.1) (p = 0.050). Within the multiple regression models, lower concordance was significantly associated with increased social constraint (p = 0.029), increased depression (p = 0.038), and increased fatigue (p = 0.006). Poor relationship satisfaction and concordance were significantly associated with poor physical and psychosocial outcomes. The maintenance of relationships should remain a focus through difficulties of cancer and into survivorship for survivors, partners, and providers.

Improving understanding of behaviors that increase or reduce cancer risk for different Hispanic groups is a public health priority; such knowledge is sparse in new gateway immigration locations such as Indiana. The aims of this study were to: 1) describe cancer beliefs and cancer preventive/risk reduction behaviors (physical activity, tobacco, and alcohol use) among Hispanic adults; 2) examine differences in cancer beliefs and preventive behaviors by country/territory of birth, socioeconomic status, and area of residence (urban vs. rural); and 3) determine predictors of engagement in cancer prevention and risk reduction behaviors in this population. A cross-sectional online survey targeted adult Indiana residents who identified as Latino, Hispanic, or Spanish recruited using Facebook-targeted advertising. Complete survey data from 1520 respondents were analyzed using descriptive, unadjusted, and adjusted models. The majority of respondents believed they were unlikely to get cancer but held many other fatalistic beliefs about cancer. Only 35.6% of respondents had received the HPV vaccine, 37.6% reported they were currently smoking cigarettes, and 64% reported occasional or frequent drinking of alcohol. Respondents spent an average of 3.55 days per week engaged in moderate exercise. Differences were observed by country/territory of birth, income, and education but not by rural residence status. Predictors of cancer risk/risk reduction behaviors were identified. The Hispanic population in Indiana is diverse and effective interventions for cancer prevention should be culturally targeted based on country/territory of birth and individually tailored based on cancer-related beliefs.