Roadmap for implementing the Chronic Care Model for weight management: Healthcare Institution's Response to Obesity (HIRO)

Background. Excess weight and obesity are at epidemic proportions in the United States and place individuals at increased risk for a variety of chronic conditions. Rates of diabetes, high blood pressure, coronary artery disease, stroke, cancer, and arthritis are all influenced by the presence of obesity. Small reductions in excess weight can produce significant positive clinical outcomes. Healthcare organizations have a vital role to play in the identification and management of obesity. Currently, healthcare providers do not adequately diagnose and manage excess weight in patients. Lack of skill, time, and knowledge are commonly cited as reasons for non-adherence to recommended standards of care. The Chronic Care Model offers an approach to healthcare organizations for chronic disease management. The model consists of six elements that work together to empower both providers and patients to have more productive interactions: the community, the health system itself, self-management support, delivery system design, decision support, and clinical information systems. The model and its elements may offer a framework through which healthcare organizations can adapt to support, educate, and empower providers and patients in the management of excess weight and obesity. Successful management of excess weight will reduce morbidity and mortality of many chronic conditions. Purpose. The purpose of this review is to synthesize existing research on the effectiveness of the Chronic Care Model and its elements as they relate to weight management and behaviors associated with maintaining a healthy weight. Methods: A narrative review of the literature between November 1998 and November 2008 was conducted. The review focused on clinical trials, systematic reviews, and reports related to the chronic care model or its elements and weight management, physical activity, nutrition, or diabetes. Fifty-nine articles are included in the review. Results. This review highlights the use of the Chronic Care Model and its elements that can result in improved quality of care and clinical outcomes related to weight management, physical activity, nutrition, and diabetes. Conclusions. Healthcare organizations can use the Chronic Care Model framework to implement changes within their systems to successfully address overweight and obesity in their patient populations. Specific recommendations for operationalizing the Chronic Care Model elements for weight management are presented.^

Latino perceptions of and barriers to preventive healthcare maintenance in the southwest United States

Between the 1990 and 2000 Censuses, the Latino population accounted for 40% of the increase in the nation’s total population. The growing population of Latinos underscores the importance for understanding factors that influence whether and how Latinos take care of their health. According to the U.S. Department of Human Health Service’s Office of Minority Health (OMH), Latinos are at greater risk for health disparities (2003). Factors such as lack of health insurance and access to preventive care play a major role in limiting Latino use of primary health care (Institute of Medicine, 2005). Other significant barriers to preventive health care maintenance behaviors have been identified in current literature such as primary care physician interaction, self-perceived health status, and socio-cultural beliefs and traditions (Rojas-Guyler, King, Montieth and 2008; Meir, Medina, and Ory, 2007; Black, 1999). Despite these studies, there remains less information regarding interpersonal perceptions, environmental dynamics and individual and cultural attitudes relevant to utilization of healthcare (Rojas-Guyler, King, Montieth and 2008; Aguirre-Molina, Molina and Zambrana, 2001). Understanding the perceptions of Latinos and the barriers to health care could directly affect healthcare delivery. Improved healthcare utilization among Latinos could reduce the long term health consequences of many preventable and manageable diseases. The purpose of this study was to explore Latino perceptions of U.S. health care and desired changes by Latinos in the U.S. healthcare system. The study had several objectives, including to explore perceived barriers to healthcare utilization and the resulting effects on health among Latinos, to describe culturally influenced attitudes about health care and use of health care services among Latinos, and to make recommendations for reducing disparities by improving healthcare and its utilization. The current study utilized data that were collected as part of a larger study to examine multidimensional, cross-cultural issues relevant to interactions between healthcare consumers and providers. Qualitative methods were used to analyze four Spanish-language focus group transcripts to interpret cultural influences on perceptions and beliefs among Latinos. Direct coding of transcript content was carried out by two reviewers, who conducted independent reviews of each transcript. Team members developed and refined thematic categories, positive and negative cases, and example text segments for each theme and sub-theme. Incongruities of interpretations were resolved through extensive discussion. Study participants included 44 self-identified Latino adults (16 male, 28 female) between age 18 and 64 years. Thirty seven (84.1%) of the participants were immigrants. The study population comprised eight ethnic subgroups. While 31% of the participants reported being employed on a full-time basis, only 18.4% had medical insurance that was private or employee sponsored. Five major themes regarding the perceptions and healthcare utilization behaviors of Latinos were consistent across all focus groups and were identified during the analysis. These were: (1) healthcare utilization, experience, and access; (2) organizational and institutional systems; (3) communication and interpersonal interactions between healthcare provider, staff, and patient; (4) Latinos’ perception of their own health status; (5) cultural influences on healthcare utilization, which included an innovation termed culturally-bound locus of control. Healthcare utilization was directly influenced by healthcare experience, access, current health status, and cultural factors and indirectly influenced by organizational systems. There was a strong interdependence among the main themes. The ability to communicate and interact effectively with healthcare providers and navigate healthcare systems (organizational and institutional access) significantly influenced the participant’s health care experience, most often (indirectly) impacting utilization negatively. ^ Research such as this can help to identify those perceptions and attitudes held by Latinos concerning utilization or underutilization of healthcare systems. These data suggest that for healthcare utilization to improve among Latinos, healthcare systems must create more culturally competent environments by providing better language services at the organizational level and more culturally sensitive providers at the interpersonal level. Better understanding of the complex interactions between these impediments can aid intervention developments, and help health providers and researchers in determining appropriate, adequate, and effective measurers of care to better increase overall health of Latinos.^

Quality in healthcare organizations: Its meaning and measurement

This dissertation explores two important aspects of quality in healthcare: its meaning and its measurement. For a better understanding of what quality means, the history of quality in the manufacturing and service industries is reviewed. Concepts that are similar are pointed out as are concepts that are different. The definition introduced by the Institute of Medicine (IOM) for quality in healthcare and the six IOM aims of safety, timeliness, patient-centeredness, effectiveness, efficiency, and equitableness for a high quality healthcare system are adopted. The current activities by various organizations that proclaim improvement in quality or measurement of quality as their goal are reviewed. This is followed by examining what is offered by these organizations in terms of how many of IOM aims they address.^ This dissertation ends by offering a quality measurement framework that satisfies all IOM aims. Operational aspects of the measurement framework are discussed. Future areas of research are also discussed.^

Performance in healthcare organizations: The quality dimension

In the context of a healthcare organization, such as a hospital that provides medical care to its community, performance cannot be measured without special attention to quality. Indeed, quality is as important as finance not only in measuring performance for the organization, but also in securing the organization's viability and competitiveness in the long run.^ Yet quality today is not adequately understood and managed. An inductive framework for integrating finance and quality for purposes of organizational performance measurement as well as strategic planning is proposed in this dissertation. Future areas of research are discussed.^

The movement toward patient safety: State action related to reporting and disclosure of healthcare-associated infections

Increasing attention has been given to the problem of medical errors over the past decade. Included within that focused attention has been a strong interest in reducing the occurrence of healthcare-associated infections (HAIs). Acting concurrently with federal initiatives, the majority of U.S. states have statutorily required reporting and public disclosure of HAI data. Although the occurrence of these state statutory enactments and other state initiatives represent a recognition of the strong concern pertaining to HAIs, vast differences in each state’s HAI reporting and public disclosure requirements creates a varied and unequal response to what has become a national problem.^ The purpose of this research was to explore the variations in state HAI legal requirements and other state mandates. State actions, including statutory enactments, regulations, and other initiatives related to state reporting and public disclosure mechanisms were compared, discussed, and analyzed in an effort to illustrate the impact of the lack of uniformity as a public health concern.^ The HAI statutes, administrative requirements, and other mandates of each state and two U.S. territories were reviewed to answer the following seven research questions: How far has the state progressed in its HAI initiative? If the state has a HAI reporting requirement, is it mandatory or voluntary? What healthcare entities are subject to the reporting requirements? What data collection system is utilized? What measures are required to be reported? What is the public disclosure mechanism? How is the underlying reported information protected from public disclosure or other legal release?^ Secondary publicly available data, including state statutes, administrative rules, and other initiatives, were utilized to examine the current HAI-related legislative and administrative activity of the study subjects. The information was reviewed and analyzed to determine variations in HAI reporting and public disclosure laws. Particular attention was given to the seven key research questions.^ The research revealed that considerable progress has been achieved in state HAI initiatives since 2004. Despite this progress, however, when reviewing the state laws and HAI programs comparatively, considerable variations were found to exist with regards to the type of reporting requirements, healthcare facilities subject to the reporting laws, data collection systems utilized, reportable measures, public disclosure requirements, and confidentiality and privilege provisions. The wide variations in state statutes, administrative rules, and other agency directives create a fragmented and inconsistent approach to addressing the nationwide occurrence of HAIs in the U.S. healthcare system. ^

Capitalizing on success against childhood HIV/AIDS in Botswana: Towards a comprehensive healthcare policy for pediatric oncology in Botswana

Pediatric HIV/AIDS in sub-Saharan Africa has been a major public health crisis with an estimated 3.5 million children infected. Baylor International Pediatric AIDS Initiative (BIPAI) has created a network of centers providing care and treatment for these children in several countries. In Botswana, where the first BIPAI center in Africa was opened, childhood mortality from HIV/AIDS is now less than 1%. Botswana is a middle-income country that previously held the highest HIV prevalence rate in the world. Efforts against HIV/AIDS have resulted in the building of a strong medical infrastructure with clear success against pediatric HIV/AIDS. The WHO predicts the next global health crisis will be cancer. Given the increased incidence of cancer in the setting of HIV/AIDS, Botswana has already implemented strategies to combat HIV-related malignancies in adults, but efforts in pediatrics have been lagging. This policy paper describes the importance of building on success against pediatric HIV/AIDS and extending this success to pediatric cancer in general. Specifically, it outlines a comprehensive pediatric cancer policy for the education and training of health professionals, the development of a pediatric cancer program, a pediatric cancer registry, public awareness efforts, and an appropriate, country specific pediatric cancer research agenda.^

Sacred vocation program follow up evaluation at the Baylor healthcare system

Background: The Sacred Vocation Program (SVP) (Amick B, Karff S., 2003) helps workers find meaning, spirituality, and see their job as a sacred vocation. The SVP is based on Participatory Action Research (PAR) (Minkler & Wallerstein, 1997; Parker & Wall, 1998). This study aims to evaluate the SVP implemented at the Baylor Healthcare System, Dallas-Fort Worth. ^ Methods: The study design is a qualitative design. We used data from study participants who have participated in focus groups. During these focus groups specific questions and probes regarding the effectiveness of the SVP have been asked. We analyzed the focus groups and derived themes. ^ Results: Results of this study demonstrate SVP helps graduates feel valued and important. The SVP has improved meaningful work for employees and improved a sense of belonging for participants. The program has also increased participant spirituality. The coping techniques developed during a SVP class helps participants deal with stressful situations. The SVP faces challenges of implementation fidelity, poor communication, program viability in tough economic times and implementation of phase II. Another sustainability challenge for SVP is the perception of the program being a religious one versus a spiritual program. ^ Conclusion: Several aspects of the SVP work. The phase I of SVP is successful in improving meaningful work and a sense of belonging for participants. The coping techniques help participants deal with difficult work situations. The SVP can increase effectiveness through improvements in implementation fidelity, communication and leadership commitment. ^

Observations from the Balcony: Directions for Pediatric Health Disparities Research and Policy

In 2002, the Institute of Medicine released Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, a landmark monograph documenting health disparities in the U.S. health care system. Since the publication of Unequal Treatment, the field of pediatric health disparities research has advanced significantly with a proliferation of studies examining a wide array of topics concerning inequities in child health. Advances in health care policy and legislation have also added to a heightened discourse on pediatric health disparities. While there has been substantial activity in efforts to address pediatric health disparities, questions remain regarding whether these efforts have changed the trajectory of health equity among children. The aim of this paper is to examine the practical challenges of addressing pediatric health disparities in the dynamic context of global changes in health care research, policy, and legislation relevant to children. Using the Adaptive Leadership framework, this paper outlines a conceptual model for assessing the scope of progress made in addressing pediatric health disparities, diagnoses the continued adaptive challenges of pediatric health disparities, and provides an agenda for further work and future investment.

Journeying Beyond the Balcony to the Block Party and Up to 50,000 Feet: Disparities in Children’s Health and Healthcare

Invited Commentary on “Observations from the Balcony: Directions for Pediatric Health Disparities Research and Policy".

Cost-effectiveness of intensified interventions to control healthcare-associated MRSA infections -- A systematic literature review

Methicillin Resistant Staphylococcus aureus healthcare-associated infections (MRSA HAIs) are a major cause of morbidity in hospitalized patients. They pose great economic burden to hospitals caring for these patients. Intensified Interventions aim to control MRSA HAIs. Cost-effectiveness of Intensified Interventions is largely unclear. We performed a review of cost-effectiveness literature on Intensified Interventions , and provide a summary of study findings, the status of economic research in the area, and information that will help decision-makers at regional level and guide future research.^ We conducted literature search using electronic database PubMed, EBSCO, and The Cochrane Library. We limited our search to English articles published after 1999. We reviewed a total of 1,356 titles, and after applying our inclusion and exclusion criteria selected seven articles for our final review. We modified the Economic Evaluation Abstraction Form provided by CDC, and used this form to abstract data from studies.^ Of the seven selected articles two were cohort studies and the remaining five were modeling studies. They were done in various countries, in different study settings, and with different variations of the Intensified Intervention . Overall, six of the seven studies reported that Intensified Interventions were dominant or at least cost-effective in their study setting. This effect persisted on sensitivity testing.^ We identified many gaps in research in this field. The cost-effectiveness research in the field is mostly composed of modeling studies. The studies do not always clearly describe the intervention. The intervention and infection costs and the sources for these costs are not always explicit or are missing. In modeling studies, there is uncertainty associated with some key model inputs, but these inputs are not always identified. The models utilized in the modeling studies are not always tested for internal consistency or validity. Studies usually test the short term cost-effectiveness of Intensified Interventions but not the long results.^ Our study limitation was the inability to adjust for differences in study settings, intervention costs, disease costs, or effectiveness measures. Our study strength is the presentation of a focused literature review of Intensified Interventions in hospital settings. Through this study we provide information that will help decision makers at regional level, help guide future research, and might change clinical care and policies. ^

Service for the pseudonymization of electronic healthcare records based on ISO/EN 13606 for the secondary use of information

The availability of electronic health data favors scientific advance through the creation of repositories for secondary use. Data anonymization is a mandatory step to comply with current legislation. A service for the pseudonymization of electronic healthcare record (EHR) extracts aimed at facilitating the exchange of clinical information for secondary use in compliance with legislation on data protection is presented. According to ISO/TS 25237, pseudonymization is a particular type of anonymization. This tool performs the anonymizations by maintaining three quasi-identifiers (gender, date of birth and place of residence) with a degree of specification selected by the user. The developed system is based on the ISO/EN 13606 norm using its characteristics specifically favorable for anonymization. The service is made up of two independent modules: the demographic server and the pseudonymizing module. The demographic server supports the permanent storage of the demographic entities and the management of the identifiers. The pseudonymizing module anonymizes the ISO/EN 13606 extracts. The pseudonymizing process consists of four phases: the storage of the demographic information included in the extract, the substitution of the identifiers, the elimination of the demographic information of the extract and the elimination of key data in free-text fields. The described pseudonymizing system was used in three Telemedicine research projects with satisfactory results. A problem was detected with the type of data in a demographic data field and a proposal for modification was prepared for the group in charge of the drawing up and revision of the ISO/EN 13606 norm.

Using realist evaluation to assess primary healthcare teams’ responses to intimate partner violence in Spain

Objective: Few evaluations have assessed the factors triggering an adequate health care response to intimate partner violence. This article aimed to: 1) describe a realist evaluation carried out in Spain to ascertain why, how and under what circumstances primary health care teams respond to intimate partner violence, and 2) discuss the strengths and challenges of its application. Methods: We carried out a series of case studies in four steps. First, we developed an initial programme theory (PT1), based on interviews with managers. Second, we refined PT1 into PT2 by testing it in a primary healthcare team that was actively responding to violence. Third, we tested the refined PT2 by incorporating three other cases located in the same region. Qualitative and quantitative data were collected and thick descriptions were produced and analysed using a retroduction approach. Fourth, we analysed a total of 15 cases, and identified combinations of contextual factors and mechanisms that triggered an adequate response to violence by using qualitative comparative analysis. Results: There were several key mechanisms —the teams’ self-efficacy, perceived preparation, women-centred care—, and contextual factors —an enabling team environment and managerial style, the presence of motivated professionals, the use of the protocol and accumulated experience in primary health care—that should be considered to develop adequate primary health-care responses to violence. Conclusion: The full application of this realist evaluation was demanding, but also well suited to explore a complex intervention reflecting the situation in natural settings.

The Case Law of the ECJ concerning the Free Provision of Services : 2000 - 2005. Research Papers in Law, 2/2006

Introduction. The present overview covers the period starting from 2000 until the end of 2005.1 This is the follow-up to our overview covering the 1995-1999 period.2 The first striking feature of the present contribution is that it has to deal with almost 3,5 times as many cases as the previous one. Hence, the ECJ has gone from deciding 40 cases in the five year period between 1995- 1999 to deciding over 140 cases based on Art 49 between 2000-2005. This confirms, beyond any doubt, the tendency already observed in our previous overview, that a “third generation” case law on services is being developed at a very rapid pace by the ECJ. This third generation case law is based on the idea that Article 49 EC is not limited to striking down discriminatory measures but extends to the elimination of all hindrances to the free provision of services. This idea was first expressed in the Tourist Guide cases, the Greek and Dutch TV cases and most importantly in the Säger case.3 It has been confirmed ever since. As was to be expected, this broad brush approach of the Court’s has led to an ever-increasing amount of litigation reaching Luxemburg. It is clear that, if indicators were used to weight the importance of the Court’s case law during the relevant period, services would score much higher than goods, both from a quantitative and from a qualitative perspective.4 Hence, contrary to the previous overview, this one cannot deal in detail with any of the judgments delivered during the reference period. The aim of the present contribution is restricted to presenting the basic trends of the Court’s case law in the field of services Therefore, the analysis follows a fundamentally horizontal approach, fleetingly considering the facts of individual cases, with a view to identifying the conceptual premises of the Court’s approach to the free movement of services. Nonetheless, the substantial solutions adopted by the Court in some key topics, such as concession contracts, healthcare services, posted workers and gambling, are also presented as case studies. In this regard, the analysis is organized in four sections. First we explore the (ever expanding) scope of the freedom to provide services (Section 2), then we go on to identify the nature of the violations and of justifications thereto (Section 3), before carrying out some case studies to concretely illustrate the above (Section 4). Then, for the sake of completeness, we try to deduce the general principles running through the totality of the relevant case law (Section 5). Inevitably, some concluding remarks follow (Section 6).5

Attitudes of the autism community to early autism research

Investigation into the earliest signs of autism in infants has become a significant sub-field of autism research. This work invokes specific ethical concerns such as use of 'at-risk' language, communicating study findings to parents and the future perspective of enrolled infants when they reach adulthood. This study aimed to ground this research field in an understanding of the perspectives of members of the autism community. Following focus groups to identify topics, an online survey was distributed to autistic adults, parents of children with autism and practitioners in health and education settings across 11 European countries. Survey respondents (n = 2317) were positively disposed towards early autism research, and there was significant overlap in their priorities for the field and preferred language to describe infant research participants. However, there were also differences including overall less favourable endorsement of early autism research by autistic adults relative to other groups and a dislike of the phrase 'at-risk' to describe infant participants, in all groups except healthcare practitioners. The findings overall indicate that the autism community in Europe is supportive of early autism research. Researchers should endeavour to maintain this by continuing to take community perspectives into account.

“Dismissingness always matters”: An examination of tobacco smoking, frequency of visits to healthcare providers, and trust in the provider as potential mediators between attachment style dismissingness and diabetes health status

Thesis (Master's)--University of Washington, 2016-06