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Journal of Primary Care & Community... 2023The onset of the COVID-19 pandemic challenged healthcare providers to adapt their models of care and leverage technology to continue to provide necessary care while...
BACKGROUND
The onset of the COVID-19 pandemic challenged healthcare providers to adapt their models of care and leverage technology to continue to provide necessary care while reducing the likelihood of exposure. One setting that faced a unique set of challenges and opportunities was free and charitable clinics. In response to the emerging pandemic, The North Carolina Association for Free and Charitable Clinics (NCAFCC) offered their 66 member clinics access to a telehealth platform, free of charge.
OBJECTIVE
This paper explores the varied perspectives of leaders in the NCAFCC member clinics regarding the implementation of telehealth services to facilitate continuity of care for patients during the height of the pandemic.
DESIGN
This qualitative study is part of a broader research effort to understand and contextualize the experience of implementing and using telehealth services by North Carolina free and charitable clinics during and after the COVID-19 pandemic. The research team conducted 13 key informant interviews and employed thematic analysis and grounded theory to explore critical themes and construct a model based on the CFIR to describe the use of telehealth in free and charitable clinics.
RESULTS
Twelve clinic managers and executive directors from free and charitable clinics across the state participated in the key informant interviews providing their unique perspective on the experience of implementing telehealth services in a free and charitable clinic environment during the COVID-19 pandemic. When examined within the lens of the consolidated framework for implementation research (CFIR), 3 key themes emerged from the key informant interviews: mission driven patient centered care, resilience and resourcefulness, and immediate implementation.
CONCLUSIONS
This study aligns with existing literature regarding telehealth implementation across other safety net provider settings and highlights the key implementation factors, organizational elements, provider perspectives, and patient needs that must collectively be considered when implementing new technologies, especially in a low-resource, high need healthcare setting. The study showcases the implementation climate, resourcefulness, and mission driven approach that allowed many NCAFCC clinics to respond to an emergent situation by adopting and implementing a telehealth platform in a period of 2 weeks or less.
Topics: Humans; COVID-19; Pandemics; Ambulatory Care Facilities; Health Personnel; Telemedicine
PubMed: 38041422
DOI: 10.1177/21501319231213783 -
Expert Reviews in Molecular Medicine Feb 2022FLASH radiotherapy is a novel technique that has been shown in numerous preclinical in vivo studies to have the potential to be the next important improvement in cancer... (Review)
Review
FLASH radiotherapy is a novel technique that has been shown in numerous preclinical in vivo studies to have the potential to be the next important improvement in cancer treatment. However, the biological mechanisms responsible for the selective FLASH sparing effect of normal tissues are not yet known. An optimal translation of FLASH radiotherapy into the clinic would require a good understanding of the specific beam parameters that induces a FLASH effect, environmental conditions affecting the response, and the radiobiological mechanisms involved. Even though the FLASH effect has generally been considered as an in vivo effect, studies finding these answers would be difficult and ethically challenging to carry out solely in animals. Hence, suitable in vitro studies aimed towards finding these answers are needed. In this review, we describe and summarise several in vitro assays that have been used or could be used to finally elucidate the mechanisms behind the FLASH effect.
Topics: Ambulatory Care Facilities; Animals; Humans; Radiation Oncology; Radiobiology; Research Design; Translations
PubMed: 35225211
DOI: 10.1017/erm.2022.5 -
Journal of General Internal Medicine Apr 2016Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex,... (Review)
Review
BACKGROUND
Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.
METHODS
We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.
RESULTS
Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.
DISCUSSION
There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
Topics: Ambulatory Care Facilities; Clinical Trials as Topic; Delivery of Health Care; Hospitals; Humans; Nursing Homes; Observational Studies as Topic; Program Evaluation; Quality of Health Care; Reimbursement, Incentive
PubMed: 26951276
DOI: 10.1007/s11606-015-3567-0 -
Muscle & Nerve Jul 2022In response to coronavirus disease 2019 (COVID-19) pandemic restrictions int 2020, our face-to-face (F2F) multidisciplinary neuromuscular clinic (NMC) transitioned to...
INTRODUCTION/AIMS
In response to coronavirus disease 2019 (COVID-19) pandemic restrictions int 2020, our face-to-face (F2F) multidisciplinary neuromuscular clinic (NMC) transitioned to widespread use of telehealth (TH). This study aimed to (1) understand parent/guardian, child, and clinician perceptions of TH; (2) examine TH-related changes in clinical activity; and (3) use these findings to inform a future model of care for the NMC.
METHODS
A clinical audit was undertaken to examine clinical activity throughout 2018-2020. Online surveys were distributed to clinicians and parents of children attending the NMC via TH in 2020. A working group of clinicians created a checklist to guide a future hybrid model of TH and F2F care.
RESULTS
Total clinical activity in 2020 was maintained from previous years; 62.8% of all appointments occurred via TH, and 82.3% of patients attended NMC by TH at least once. Ninety-nine parents (30.6% response rate), 52 children, and 17 clinicians (77% response rate) responded to the survey. All groups reported better interaction when F2F compared to TH. Eighty percent of parents identified advantages of TH and reported lower levels of stress. A lack of "hands-on" physical assessment was identified by parents and clinicians as a TH limitation. Most families (68.1% of parents; 58.8% of children) and all clinicians indicated a preference for a mix of TH and F2F NMC appointments in the future.
DISCUSSION
This study has informed a checklist to guide future TH use in a new hybrid model of care. Further investigation is required to assess health impacts of TH use in pediatric neuromuscular care.
Topics: Ambulatory Care Facilities; COVID-19; Child; Humans; Pandemics; Telemedicine
PubMed: 35426158
DOI: 10.1002/mus.27557 -
Contraception Jun 2022To assess whether having an abortion in Texas, a U.S. state with many restrictive abortion laws, is associated with increased time between contacting an abortion...
OBJECTIVE
To assess whether having an abortion in Texas, a U.S. state with many restrictive abortion laws, is associated with increased time between contacting an abortion provider and receiving an abortion, compared to having an abortion in California, a less restrictive U.S. state.
STUDY DESIGN
This is a multisite, cross-sectional survey of 434 patients in 12 abortion facilities (ambulatory surgical centers and clinics) in Texas (n = 291) and three abortion clinics in California (n = 143) from 2018 to 2019. At 11 facilities in Texas the response rate was 76%. The response rate was not collected at other sites. We compare the clinical-contact-to-abortion time interval between the facilities in these two states using mixed-effects multivariable logistic regression, adjusting for age, race, education, household income, parity, marital status, and insurance status. We also compare barriers to scheduling and traveling to abortion appointments.
RESULTS
Median clinical-contact-to-abortion time is similar among respondents in Texas and California [(9 vs 8 days, p = 0.86). The odds of having a clinical-contact-to-abortion time ≥7 days is similar among respondents in Texas compared to California (adjusted odds ratio 1.0 (95% confidence interval, 0.4-2.6, p = 0.98). Respondents in Texas travel farther for their abortion (mean 22.1 vs 13.5 miles, p < 0.01), are more likely to sell something of value or delay paying another expense to pay for their abortion (49.7% vs 11.4%, p < 0.01), and to miss work to attend their abortion (73.9% vs 61.3%, p = 0.03).
CONCLUSIONS
In this study, we found no difference in clinical-contact-to-abortion time between respondents in Texas and those in California. Respondents in Texas, however, face other significant barriers in obtaining abortion care, which result in life disruptions and financial hardship.
IMPLICATIONS
Patients face greater financial barriers when seeking abortion in Texas compared to California. Though we found no significant difference in clinical-contact-to-abortion time in this sample between the two states, clinical-contact-to-abortion time may be a useful measure of facility congestion and the obstacles patients face obtaining abortion care.
Topics: Abortion, Induced; Ambulatory Care Facilities; California; Cross-Sectional Studies; Female; Health Services Accessibility; Humans; Pregnancy; Texas
PubMed: 34971611
DOI: 10.1016/j.contraception.2021.12.009 -
BMJ Open Diabetes Research & Care Nov 2023Patient-reported outcome (PRO) measures are increasingly used in clinical diabetes care to increase patient involvement and improve healthcare services. The objectives... (Review)
Review
BACKGROUND
Patient-reported outcome (PRO) measures are increasingly used in clinical diabetes care to increase patient involvement and improve healthcare services. The objectives were to identify instruments used to measure PROs in outpatient diabetes clinics and to investigate the use of these PRO measures alongside the experiences of patients and healthcare personnel in a clinical setting.
RESEARCH DESIGN AND METHODS
A scoping review was conducted according to the framework of Arksey and O'Malley with scoping searches of Cinahl, EMBASE, Medline and Health and Psychosocial Instruments. Studies reporting on adults with diabetes in a clinical setting where the PRO measure response directly affected patient care were eligible for inclusion.
RESULTS
In total, 35 197 citations were identified, of which 7 reports presenting 4 different PRO measures were included in the review. All four of the included items measured psychosocial aspects of diabetes, and three included elements of the Problem Areas in Diabetes scale. All the patients were satisfied with the use of PRO measures in clinical care, whereas the level of satisfaction among healthcare personnel with PRO measures varied within and among studies.
CONCLUSIONS
The limited number of eligible studies in this review suggests that research on PRO measures for diabetes outpatient care is scarce. Patients welcome the opportunity to express their concerns through the systematic collection of PRO measures, and some healthcare personnel value the broader insight that PRO measures provide into the impact of diabetes on patients' lives. However, the heterogeneity among services and among patients challenges the implementation of PRO measures. Research is needed to explore how PRO measures in clinical outpatient care affect healthcare personnel workflow.
REVIEW REGISTRATION
https://doi.org/10.17605/OSF.IO/46AHC.
Topics: Adult; Humans; Health Personnel; Patient Reported Outcome Measures; Ambulatory Care; Ambulatory Care Facilities; Diabetes Mellitus
PubMed: 37963648
DOI: 10.1136/bmjdrc-2023-003628 -
Dermatologic Clinics Oct 2021The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as... (Review)
Review
The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the "new normal" in various domains of dermatology practice, namely, dermatology consultation, procedural dermatology, and phototherapy, is also provided.
Topics: Ambulatory Care Facilities; COVID-19; Dermatology; Health Services Accessibility; Humans; Office Visits; Primary Health Care; Skin Diseases; Telemedicine
PubMed: 34556248
DOI: 10.1016/j.det.2021.05.004 -
Annals of Neurology Apr 2022The objective of this study was to assess the feasibility, acceptability, and benefits of a teleneurology clinic serving adults usually attending a neurology outpatient... (Observational Study)
Observational Study
OBJECTIVE
The objective of this study was to assess the feasibility, acceptability, and benefits of a teleneurology clinic serving adults usually attending a neurology outpatient clinic in Lusaka, Zambia during the coronavirus disease 2019 (COVID-19) pandemic.
METHODS
Televisits were offered to patients scheduled for neurology appointments between March and July 2020 using the telephone, WhatsApp video, or Zoom calls based on patient accessibility. Visit outcomes were documented, and patient and neurologist satisfaction surveys were completed.
RESULTS
Of 323 patients, 195 (60%) were reachable by telephone, 179 of these were alive, and 74% (133/179) of those alive agreed to a televisit. Stroke (30%), seizures (20%), and headache (16%) were the most common diagnoses seen via televisit. Most televisits (80%) were by telephone call, 14% by WhatsApp video call, and 6% by Zoom. Nearly one-third (30%) of the patients were stable and discharged from the clinic, 32% only required medication refills, and 19% required an in-person visit. Sixty patients (out of 85 reachable and 71% response rate) and 7 of 9 neurologists (78% response rate) completed satisfaction surveys. Neurologists reported greater assessment confidence with Zoom, but confidence was high for all modalities. Patients preferring televisits (75%, 45/60) noted reduced expense and time requirements, whereas those preferring in-person visits (22%, 13/60) cited the desire for physical examinations. Overall, 98% of patients and 100% of neurologists were satisfied with televisits.
INTERPRETATION
Teleneurology visits were acceptable and feasible for adults attending an outpatient neurology clinic in Zambia and their neurologists. They offer a promising supplement to in-person visits in resource-limited settings, even when video-conference capabilities and electronic medical records are absent. ANN NEUROL 2022;91:445-454.
Topics: Adult; Aged; Aged, 80 and over; Ambulatory Care Facilities; COVID-19; Cross-Sectional Studies; Feasibility Studies; Female; Humans; Male; Middle Aged; Neurologists; Neurology; Pandemics; Patient Acceptance of Health Care; Patient Satisfaction; Prospective Studies; Smartphone; Surveys and Questionnaires; Telemedicine; Videoconferencing; Zambia
PubMed: 35150000
DOI: 10.1002/ana.26323 -
Current Oncology (Toronto, Ont.) May 2022Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability...
Ambulatory cancer centers face a fluctuating patient demand and deploy specialized personnel who have variable availability. This undermines operational stability through the misalignment of resources to patient needs, resulting in overscheduled clinics, budget deficits, and wait times exceeding provincial targets. We describe the deployment of a Learning Health System framework for operational improvements within the entire ambulatory center. Known methods of value stream mapping, operations research and statistical process control were applied to achieve organizational high performance that is data-informed, agile and adaptive. We transitioned from a fixed template model by an individual physician to a caseload management by disease site model that is realigned quarterly. We adapted a block schedule model for the ambulatory oncology clinic to align the regional demand for specialized services with optimized human and physical resources. We demonstrated an improved utilization of clinical space, increased weekly consistency and improved distribution of activity across the workweek. The increased value, represented as the ratio of monthly encounters per nursing worked hours, and the increased percentage of services delivered by full-time nurses were benefits realized in our cancer system. The creation of a data-informed demand capacity model enables the application of predictive analytics and business intelligence tools that will further enhance clinical responsiveness.
Topics: Ambulatory Care Facilities; Humans; Neoplasms
PubMed: 35735427
DOI: 10.3390/curroncol29060318 -
The Journal of the American Osteopathic... Dec 2019The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven... (Review)
Review
The opioid epidemic in the United States is one of the largest modern health crises in the nation's history. The crisis has been cultivated in academic journals, driven by the medical-pharmaceutical complex, and fueled by campaigns representing the most prestigious health care organizations and advocacy groups. Comprehensive guidelines for proper prescribing have been released in addition to state-sponsored prescription drug-monitoring programs (PDMPs) in response to overprescribing habits. When considering opioid treatment for a patient, physicians should document a thorough history of pain, give an appropriate physical examination, and complete a risk assessment using the proper diagnostic tools. Considering the osteopathic philosophy and approach to chronic pain, physicians should account for an integrative treatment approach for improved patient outcomes when considering applying the osteopathic philosophy to chronic pain management. A successful treatment plan can integrate cognitive behavioral therapy and promote self-healing by treating somatic dysfunctions with osteopathic manipulative treatment. This literature review discusses how to treat patients with chronic pain and how to properly use and prescribe opioids. The researchers analyzed the history and current status of the opioid epidemic, examined opioid management in the outpatient setting, reviewed the current domestic and international opioid prescribing guidelines, and discussed the incorporation of the osteopathic philosophy to manage chronic pain.
Topics: Ambulatory Care Facilities; Analgesics, Opioid; Humans; Opioid-Related Disorders; Osteopathic Medicine; Pain Management; Practice Guidelines as Topic; Practice Patterns, Physicians'; United States
PubMed: 31790128
DOI: 10.7556/jaoa.2019.134