The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient ...factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
The US health care system is failing to deliver value and equity. Life expectancy has been declining nationally.' Health care costs in the United States are the highest in the world. Medicare ...alternative payment models have yielded modest reductions in costs but have generally not improved health or equity. Fundamental change is needed beyond redesign of alternative payment models. Health care must embrace equitable improvement in the national Vital Signs initiative, invest in primary care, and collaborate with communities.
Home Blood Pressure Monitoring (HBPM) that includes a team with a clinical pharmacist is an evidence-based intervention that improves blood pressure (BP). Yet, strategies for promoting its adoption ...in primary care are lacking. We developed potentially feasible and sustainable implementation strategies to improve hypertension control and BP equity.
We assessed barriers and facilitators to HBPM and iteratively adapted implementation strategies through key informative interviews and guidance from a multistakeholder stakeholder team involving investigators, clinicians, and practice administration.
Strategies include: 1) pro-active outreach to patients; 2) provision of BP devices; 3) deployment of automated bidirectional texting to support patients through education messages for patients to transmit their readings to the clinical team; 3) a hypertension visit note template; 4) monthly audit and feedback reports on progress to the team; and 5) training to the patients and teams. We will use a stepped wedge randomized trial to assess RE-AIM outcomes. These are defined as follows Reach: the proportion of eligible patients who agree to participate in the BP texting; Effectiveness: the proportion of eligible patients with their last BP reading <140/90 (six months); Adoption: the proportion of patients invited to the BP texting; Implementation: patients who text their BP reading ≥10 of days per month; and Maintenance: sustained BP control post-intervention (twelve months). We will also examine RE-AIM metrics stratified by race and ethnicity.
Findings will inform the impact of strategies for the adoption of team-based HPBM and the impact of the intervention on hypertension control and equity.
Registration details: www.ClinicalTrials.gov Identifier: NCT05488795.
The present study protocol describes the trial design of a clinician training intervention to improve physical activity counseling in underserved primary care settings using the 5As. The 5As (Ask, ...Advise, Agree, Assist, Arrange) are a clinical tool recommended for health behavior counseling in primary care.
The study is a two-arm randomized pilot pragmatic trial to examine a primary care clinician communication intervention on use of the 5As in discussion of physical activity in audio-recorded office visits in an ethnically diverse, low-income patient population. The study setting consists of two federally qualified community health centers in Rochester, NY. Eligible clinicians (n=15) are recruited and randomized into two groups. Group 1 clinicians participate in the training intervention first; Group 2 clinicians receive the intervention six months later. The intervention and its outcomes are informed by self-determination theory and principles of patient-centered communication. Assessment of outcomes is blinded. The primary outcome will be the frequency and quality of 5As discussions as judged by evaluating 375 audio-recorded patient visits distributed over baseline and in the post-intervention period (immediately post and at six months). Secondary outcomes will be changes in patients' perceived competence to increase physical activity (Aim 2) and patients and clinicians beliefs regarding whether pertinent barriers to promoting exercise have been reduced. (Aim 3). Exploratory outcomes (Aim 4) are potential mediators of the intervention's effect and whether the intervention affects actual enrollment in the community program recommended for exercise. The analysis will use repeated measures (in the form of recorded office visits) from each clinician at each time point and aggregate measures of Groups 1 and 2 over time.
Results will help elucidate the role of 5As communication training for clinicians on counseling for physical activity counseling in primary care. Results will explore the effectiveness of the 5As model linked to community resources for physical activity promotion for underserved groups.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Physical activity (PA) counselling is challenging in primary care. It is unknown whether clinician training on the 5As (Ask, Advise, Agree, Assist, Arrange) improves PA counselling skills.
To ...evaluate the effect of a clinician training intervention on PA counselling for underserved adults using the 5As framework.
Pragmatic pilot clinical trial was used in the study. Clinicians (n = 13) were randomly assigned to two groups. Each group received the intervention consisting of four 1-hour training sessions to teach the 5As for PA counselling. Patient-clinician visits (n = 325) were audio recorded at baseline, immediately post-intervention, and at 6 months. Outcomes were the frequency and quality of PA discussions using the 5As, assessed by blinded coders.
Patients' mean age was 44 years; 75% were African American. PA was discussed in 37% (n = 119) of visits overall and did not change from baseline to follow-up. When PA discussions occurred, the frequency of 5As increased from baseline to follow-up for Advise (51-54%), Agree (11-26%), and Assist (11-17%); however, none of the 5As had a statistically significant increase. For Agree, exploration of patient willingness to engage in PA increased from 23% at baseline to 50% at follow-up.
A clinician-directed intervention to improve PA counselling increased the frequency of Advise, Agree and Assist, and the quality of Ask and Agree statements, though the absolute numbers were small and only Agree reached statistical significance. Future research is needed to understand the factors that affect the optimal uptake and approach to 5As counselling.
Data on barriers and facilitators to prenatal oral health care among low-income US women are lacking. The objective of this study was to understand barriers/facilitators and patient-centered ...mitigation strategies related to the use of prenatal oral health care among underserved US women.
We used community-based participatory research to conduct two focus groups with eight pregnant/parenting women; ten individual in-depth interviews with medical providers, dental providers and community/social workers; and one community engagement studio with five representative community stakeholders in 2018-2019. Using an interpretive description research design, we conducted semi-structured interviews and focus groups which were audio-recorded, transcribed, and analyzed for thematic content.
We identified individual and systemic barriers/facilitators to the utilization of prenatal oral health care by underserved US women. Strategies reported to improve utilization included healthcare system-wide changes to promote inter-professional collaborations, innovative educational programs to improve dissemination and implementation of prenatal oral health care guidelines, and specialized dental facilities providing prenatal oral health care to underserved women. Moreover, smartphones have the potential to be an innovative entry point to promote utilization of prenatal oral care at the individual level.
Low-income women face multiple, addressable barriers to obtaining oral health care during pregnancy. Inter-professional collaboration holds strong promise for improving prenatal oral health care utilization.
Patient-centered communication is a means for engaging patients in partnership. However, patient centered communication has not always been grounded in theory or in clinicians' pragmatic needs. The ...objective of this report is to present a practical approach to hypertension counselling that uses the 5As framework and is grounded in theory and best communication practices.
The use of online personal health records (PHRs) threatens to transform the digital divide to a health care divide among the underserved. Little is known about underserved patients' ability to access ...online PHRs. We examined these factors among patients within safety-net practices. Among respondents (N = 654), only 12% had no experience of using a computer, and most were interested in using it to communicate with their provider. Age, sex, and race were not associated with interest in PHRs. A majority of patients have access to the Internet and are interested in using a PHR to manage their care, but they are not prepared.
Limited time and lack of knowledge are barriers to physical activity counseling in primary care. The objective of this study was to examine the effectiveness of a clinician-targeted intervention that ...used the 5As (Ask, Advise, Agree, Assist, Arrange) approach to physical activity counseling in a medically underserved patient population.
Family medicine clinicians at 2 community health centers were randomized to Group 1 or Group 2 intervention. Both clinician groups participated in 4 training sessions on the 5As for physical activity counseling; Group 2 training took place 8 months after Group 1 training. Both groups were trained to refer patients to a community exercise program. We used a pre-post analysis to evaluate the effectiveness of the intervention on clinician use of 5As. Eligible patients (n = 319) rated their clinicians' counseling skills by using a modified Physical Activity Exit Interview (PAEI) survey. Clinicians (n = 10) self-assessed their use of the 5As through a survey and interviews.
Both patient and clinician groups had similar sociodemographic characteristics. The PAEI score for both groups combined increased from 6.9 to 8.6 (on a scale of 0-15) from baseline to immediately postintervention (P = .01) and was 8.2 (P = .09) at 6-month follow-up; most of the improvement in PAEI score was due to increased use of 5As skills by Group 2 clinicians. Group 1 reported difficulty with problem solving, whereas Group 2 reported ease of referral to the community exercise program.
A clinician training intervention showed mixed results for 5As physical activity counseling.
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