Translating Research Into
Policy & Practice
Call for Papers
From Evidence to Practice: How to Do It, How to Know if
You Succeed
Chair: Andrew Nelson, HealthPartners Research Foundation
Monday, June 26 • 8:30 am – 10:00 am
●The Development of an Instrument to Measure Research
Utilization in Health Care Settings and its Implications for
the Knowledge Translation Field.
Lesa Chizawsky, BScN, Carole Estabrooks, Ph.D., Shannon
Scott-Findlay, BN, MN, Ph.D.(c), Joanne Profetto-McGrath,
Ph.D., Dwight Harley, Ph.D., Margaret Milner, MN, Anne
Hofmeyer, Ph.D.
Presented By: Lesa Chizawsky, BScN, MN student, research
assistant, Faculty of Nursing, University of Alberta, Knowledge
Utilization Studies Program, 5-112, 5th Floor Clinical Sciences
Building, Edmonton, Alberta, T6G 2G3; Tel: (780) 492-6836;
Fax: (780) 492-6186; Email: lesa@ualberta.ca
Research Objective: In the past thirty years, we have gained
considerable understanding about the concept of research
utilization. Despite these gains, measuring research utilization
validly and reliably remains a persistent challenge. While some
existing measures have been used more than once, the most
common approach to measuring research utilization has been
to develop one’s own measure with little attention to standard
psychometric methods or to post-use evaluation of the
measure’s performance. Currently, one of the most serious
limitations to furthering the study of research utilization in
health care settings is the lack of a sensitive, valid, and reliable
tool for its measurement. Such a tool will enable valid
comparisons among groups, settings and/or institutions, the
conduct of solid intervention studies, and accurate
assessment of the impact of research use on clinical and
system outcomes. In this paper, we discuss construct
clarification, the development of research utilization indicators
for the instrument and the implications a measurement tool
will have on the knowledge utilization field.
Study Design: The project utilizes both qualitative and
quantitative designs. Steps undertaken to develop the
research utilization instrument included: 1) construct
clarification, 2) indicator and item development and 3) pilot
testing the instrument to evaluate validity and reliability.
In steps one and two we used focus group methods. To clarify
the construct and develop instrument indicators, we studied
nurses across various geographic areas, educational levels
and roles.
Population Studied: The sample consisted of twenty-one
focus groups with four to eight nurses per group. Participants
were nurses of all educational backgrounds, from a diverse
geographic area and a variety of professional roles (e.g.
international experts in the knowledge translation field, nurses
in advanced practice and managerial roles, and nurse
providers including licensed practical nurses, registered
nurses, and nursing aides).
Principal Findings: Steps one and two of this project have
enable us to solidify working definitions of research utilization,
and its sub-types: a) instrumental research use - the concrete
application of research in clinical practice and b) conceptual
research use - cognitive use of research to change opinion or
mind set about a specific practice area. These concepts have
been transformed into a conceptual model that provides a
framework for the instrument development. The findings
from the focus group data suggest indicators of conceptual
and instrumental research utilization. These findings have
then been used to develop instrument items. Indicators of
conceptual and instrument research utilization include
activities such as literature searching, journal clubs and the
documentation of research based interventions in patients’
charts.
Conclusions: Developing a high quality instrument on
research utilization is essential from a theoretical, as well as, a
practical perspective. Construct clarification will aide in the
identification of a common syntax for knowledge utilization
scholars. A robust tool will provide critical information
pertaining to the effectiveness of interventions targeted at
enhancing research use and improving patient care.
Implications for Policy, Delivery, or Practice: Interventions
designed to improve research use in clinical health care
settings can never be evaluated and improved if there is no
means by which to measure their effectiveness. Use of
research-based practice and being able to evaluate this
practice is crucial if nurses are to provide high quality patient
care.
Primary Funding Source: Canadian Institutes for Health
Research
●Developing a Taxonomy of Methods for Implementing
Changes in Nursing Practice
Jennifer Leeman, MDiv, M.P.H., Dr.P.H., Margarete
Sandelowski, Ph.D., RN, FAAN
Presented By: Jennifer Leeman, MDiv, MPH, DrPH, PostDoctoral Fellow, School of Nursing, University of North
Carolina at Chapel Hill, CB #7460 Carrington Hall, Chapel
Hill, NC 27599-7460; Tel: 919-929-9135;
Email: jleeman@email.unc.edu
Research Objective: This study aims to develop a theorybased taxonomy of the methods used to implement change in
nursing practice. Implementation is defined as an active and
planned effort to mainstream a change in clinical practice
within an organization. The study’s goal is to create a clear,
mutually exclusive, and exhaustive system for categorizing
implementation methods.
Study Design: The study employs a descriptive design using
directed content analysis of published research reports. The
organizing principles for the analysis were derived from
existing theory and research on implementation. Key concepts
were identified as initial coding categories and operational
definitions were developed for each category. The provisional
coding categories were applied to the published reports.
Categories were iteratively revised throughout abstraction in
order to more fully capture the information encountered in the
review.
Population Studied: Included in the analysis were published
reports of empirical studies of the implementation of one or
more research-based practice change involving nurses. The
search was limited to reports published between January 1995
and September 2005. To date, a total of 35 articles have been
analyzed. The majority of studies were conducted in hospitals
(n=20); 12 were in outpatient settings, two in homecare and
one in a long term care facility. Thirteen of the studies
targeted nursing care and 22 targeted interdisciplinary care
processes included nursing. Most of the care processes
targeted (n=23) dealt with the management of chronic
illnesses and conditions.
Principal Findings: The evolving taxonomy categorizes
methods according to eleven implementation strategies and
six communication channels. Implementation strategies
include reminders; data collection and feedback; education;
financial incentives; organizational policy; local
development/adaptation of the practice change; assessment
of barriers/facilitators to change; centralized management
(e.g. a case manager); modifications to the medical record;
environmental change; and marketing. Communication
channels include peer, manager, team, print/electronic, and
patient. The taxonomy includes a further distinction between
whether the communication channel emanated from within or
via an agent external to the organization implementing the
change. External change agents included government
agencies, academic researchers, and professional and other
organizations. A description will be provided of the frequency
of each strategy and channel, the ways they are combined, and
variations in the ways they are used in nursing.
Conclusions: Implementation research suffers from a lack of
consistent terminology for the methods employed and from
inattention to differences in the relevance of methods across
different disciplines. The taxonomy presented in this paper
differs from prior taxonomies by focusing on nursing and by
providing a clear, mutually exclusive, and exhaustive approach
to describing implementation methods.
Implications for Policy, Delivery, or Practice: The limited
success of many efforts to implement change in practice may,
in part, be due to the absence of a theoretical rationale for
matching implementation strategies to differences in the
nature and context of the practice change. By deriving the
initial coding strategy from theory, the taxonomy links the
methods to theoretical constructs that may inform the
selection of methods across differing practice changes and
settings.
Primary Funding Source: National Institute of Nursing
Research
●Factors Affecting Compliance with Diabetes
Hypertension Guidelines
Julie Lowery, Ph.D., M.H.S.A., Sarah L. Krein, Ph.D., RN, Lee
A. Green, M.D., M.P.H., Leon Wyszewianski, Ph.D., Hyungjin
Myra Kim, Sc.D., Christine P. Kowalski, M.P.H.
Presented By: Julie Lowery, Ph.D., MHSA, Associate Director,
Health Services Research & Development, VA Medical Center,
2215 Fuller Road, Ann Arbor, MI 48105; Tel: (734) 768-7100
X6222; Fax: (734) 761-2617; Email: julie.lowery@med.va.gov
Research Objective: The objective of this study was to test a
formal framework for identifying which strategies are most
likely to be effective for the translation of research findings
into clinical practice. The framework’s underlying premises
are that there is no one-size-fits-all approach to changing
clinicians’ behaviors, and that the optimal mix and exact
nature of translation strategies varies depending on specific
attributes of the targeted clinicians.
Study Design: The primary hypothesis tested by the study is
that compliance with medication guidelines for diabetes
patients with hypertension varies by physician category and
guideline implementation strategy. A cross-sectional,
observational design, using both primary and secondary data
collection, was employed. Data were analyzed using logistic
regression, clustering within provider. The dependent variable
was adherence to medication guidelines (yes/no);
independent variables included site-specific implementation
strategies and physician category.
Population Studied: Phase 1 consisted of conducting semistructured telephone interviews with clinical representatives at
participating VA medical centers to determine what strategies
were implemented for meeting diabetes hypertension
guidelines in the time period from 1999-2001. In phase 2, all
primary care physicians (PCPs) in these same VAMCs were
sent a one-page questionnaire regarding their responses to
research findings about the efficacy of specific clinical
practices, which was used for categorizing. In phase 3,
secondary data on diabetic outpatients, their hypertension
prescriptions, blood pressures, and primary care providers
were obtained for FY 1999 and 2000 (post-guideline
implementation). Patient data were matched to each
participating PCP.
Principal Findings: Results from the interviews showed that
all of the participating sites used some type of educational
approach to implement the guidelines, whether written, a
presentation, or a conference. Over 90% of the sites also
provided group or individual feedback on physician
performance on the guidelines, and over 75% implemented
some type of reminder system. A minority of sites used
monetary incentives, penalties, or barrier reduction. Of 747
questionnaires distributed to primary care physicians, 304
were returned (response rate of 40.7%). Patient data were
matched to 163 of the responding physicians. Logistic
regression analysis (n = 1174 patients, clustered by physician)
showed that barrier reduction strategies (i.e., guideline
implementation strategies designed to reduce, or at least not
increase, physician time demands and task complexity) were
the only ones that improved guideline adherence—particularly
for physicians low on the conformity scale, but less so for
conformists. Education may have been necessary, but it was
clearly not sufficient; all sites included education in their mix
of strategies, but those doing a great deal of it saw no more
effect than those doing the minimum. Incentives had no
discernible effect.
Conclusions: Our findings do not support our original
hypothesis. Instead, they show that only barrier removal is
associated with guideline compliance, regardless of provider
type (although its effect varies somewhat by provider type.)
Implications for Policy, Delivery, or Practice: Efforts for
improving adherence to practice guidelines (and other
evidence-based practice recommendations) should be
directed at the organizational level, rather than the provider.
Specific interventions should focus on organizational change
strategies, such as barrier reduction.
Primary Funding Source: VA
●Contextualizing the fFndings of a Croup Guideline
Knowledge Translation Study
Shannon Scott-Findlay, BN, MN, Ian Graham, Ph.D., Rena
Pandya, M.P.H., Terry Klassen, M.D., MSc, David Johnson,
M.D.
Presented By: Shannon Scott-Findlay, BN, MN, Doctoral
candidate, , University of Alberta, Alberta Centre for Child
Health Evidence, Room 9432 Aberhart Centre one, Edmonton,
Alberta, T6G 2J3; Tel: 780.492.5074; Fax: 780.407.6435;
Email: shannon.scott-findlay@ualberta.ca
Research Objective: The purpose of this project is to increase
understanding of how a practice guideline for management of
croup is transferred (or not transferred) into practice in the
context of an implementation trial. It includes identifying
barriers and supports to the uptake of a croup management
guideline. We were presented with a unique opportunity to
study the process of research transfer of guideline
recommendations about care of children with croup in 12
hospitals that had been part of an implementation study
(referred to as the Croup CPG CRCT). The findings from this
study help contextualize the findings from the implementation
study and better understand the determinants of the use of
the croup guidelines. The overall aim of the CROUP CPG
CRCT was to identify, from a societal perspective, the costs
and associated benefits of three strategies for disseminating
and implementing (passive dissemination, interactive
educational sessions, and opinion leaders) a practice
guideline that addresses the management of croup.
Study Design: A qualitative case study research methodology
involving 12 of the 24 hospitals involved in the initial
randomized controlled trial was used to explore and describe
the process of knowledge translation that occurred at these
hospitals. The 12 hospitals included were chosen in equal
numbers from each of the three intervention arms, and
include both smaller and larger hospitals. We also specifically
tried to choose hospitals within each intervention arm which
were ‘poor responders’ and ‘good responders’. Data for the
case study is derived largely from personal or telephone
interviews and focus groups with key informants from the 12
hospitals and review of policy documents related to
institutional practices for treating croup.
Principal Findings: Our findings correspond to the six
elements of the Ottawa Model of Research Use. We will
discuss our findings in relation to the evidence-base of the
practice guideline, potential adopters (those whose behavior
or practice one would like to change), the practice
environment, the interventions to promote the uptake of the
guideline, the adoption of the guideline and their perspectives
on the outcomes resulting from the implementation of the
guideline. The findings also illuminate why passive
dissemination of clinical practice guidelines does not work
and highlights that unidisciplinary knowledge translation
strategies are not effective as interdisciplinary ones
Conclusions: Through this study increased knowledge was
developed regarding how a clinical practice guideline is
transferred or not transferred into practice. Furthermore, we
acquired a deeper and richer understanding of the barriers
and supports to the uptake of a croup management guideline.
Implications for Policy, Delivery, or Practice: The findings
point to the importance of doing qualitative studies in
association with randomized controlled trials. While the RCT
findings highlight which knowledge translation strategies are
most effective, it is through the detailed qualitative findings
that particular nuances become apparent and that the findings
become contextualized. General principles from this study’s
findings will be able to inform future clinical practice guideline
and knowledge translation work with this population.
Primary Funding Source: No Funding
●Using Crew Resource Management to Improve Diabetes
Care and Patient Outcomes in an Inner-city Primary Care
Clinic
Cathy R. Taylor, DrPH, Joseph T. Hepworth, Ph.D., Peter I.
Buerhaus, Ph.D., Robert S. Dittus, M.D., Theodore Speroff,
Ph.D.
Presented By: Cathy R. Taylor, Dr.P.H., Assistant Professor,
School of Nursing, Vanderbilt University, 461 21st Avenue
South, Nashville, TN 37240; Tel: (615)936-6160; Fax: (615)9360228; Email: cathy.taylor@vanderbilt.edu
Research Objective: Diabetes is the leading cause of adult
blindness, end stage kidney disease, and non-traumatic lower
extremity amputation in the United States despite established
guidelines for preventing or postponing these outcomes.
Most diabetes care is delivered in out-patient primary care
settings and is sub-optimal among population sub-groups
such as the poor and racial/ethnic minorities. Microsystem redesign has been employed to more effectively address gaps in
service delivery. Aviation-based team training, Crew Resource
Management (CRM), has been proposed as a promising
framework for improving patient care and safety. We assessed
the impact and practical usefulness of CRM on diabetes care
processes and patient outcomes in an inner-city primary care
clinic.
Study Design: An aviation crew error model was used to
guide development of the CRM intervention which included
clarification and re-distribution of diabetes care tasks; team
training on human factors related to error; situation
awareness; responsibility and accountability; interpersonal
communication; and standardization of information exchange,
briefing, and cross-check tools. Using 1683 clinic visits (160
pre-intervention and 122 post-intervention clinic days)
interrupted time series analysis was used to assess
significance of pre- and post-intervention differences in
adherence to recommended care guidelines and clinical
outcomes (blood sugar, blood pressure, lipids, microalbumin,
foot examination). Work flow and structured communication
changes were observed, and staff turnover was reported by the
clinic director.
Population Studied: The clinic serves 9,000 inner-city
patients. Ninety percent are TennCare/Medicaid recipients,
and 40% of all visits are un-scheduled. All patients diagnosed
with diabetes (N=619) reporting to the clinic for any care
between 4/1/04 and 5/31/05 were included. The sample was
61% female (n=379), mean age was 50.6 years (SD=12.5
years), and self-reported race/ethnicity was 42% White, 39%
Black, and 19% other/unknown.
Principal Findings: CRM training and tools enabled staff to
reorganize work processes, work as a team with new roles and
responsibilities, coordinate and communicate their actions,
and check for care omissions using checklists and briefings.
Significant improvements in microalbumin testing (6.97%,
p<.01) and in the percent of patients with decreased
microalbumin levels (5.7%, p<.01) occurred along with
modest improvements in provision of other recommended
examinations. Improvement trends (p<.10) were observed for
blood pressure, low density lipoprotein, amputation risk, and
patient weight. All improvements were sustained despite high
staff turnover historically associated with deterioration in
these measures. Patient visit time decreased. Staff reported
high satisfaction and a sense of order absent in the preintervention diabetes care milieu. New employee orientation
to diabetes care processes decreased from several days to <1
day.
Conclusions: Diabetes care and information exchange
processes were re-designed using CRM principles. CRM
management tools enabled prevention of service omissions in
the short term and produced sustained clinical improvements
and changes in the organizational culture for continuous
improvement.
Implications for Policy, Delivery, or Practice: Few guidelines
exist to direct translation of scientific evidence into clinical
practice, particularly for vulnerable populations. CRM
represents a framework for structuring routine work and
clinical decision-making around a common goal to produce
welcome efficiencies in under-resourced clinics serving
medically indigent patients.
Primary Funding Source: Pfizer Post-doctoral Fellowship
Call for Papers
From Research to Policy: Dealing with the
“So What?” Factor
Chair: Mary Pittman, Health Research and Education Trust
Tuesday, June 27 • 10:30 am – 12:00 pm
●The Administration on Aging (AoA) and Centers for
Medicare and Medicaid Services (CMS) Aging and
Disability Resource Center Grants: Supporting the a New
Initiative with Clear Federal Guidance and Technical
Assistance
Lisa Alecxih, M.P.A. Karen Linkins, Ph.D., Carrie Blakeway,
M.P.A., Susan Reinhard, Ph.D.
Presented By: Lisa Alecxih, Master Public Affairs, Vice
President, , The Lewin Group, 3130 Fairview Park, Suite 800,
Falls Church, VA 22042; Tel: 703-269-5542; Fax: 703-268-5503;
Email: lisa.alecxih@lewin.com
Research Objective: Through a historic partnership between
AoA and CMS, 43 states and territories have initiated pilots to
streamline access to long-term care. Through Resource
Centers, people with disabilities have access to the wide range
of support services they need through a single entry point or
no wrong door model. This requires that ADRCs integrate or
so closely coordinate intake, assessment and eligibility
screening for publicly funded services that the process is a
seamless one for consumers. AoA and CMS sponsored
Technical Assistance providers have joined forces to provide
the grantees with the information and resources necessary for
their grants to meet the federal objectives, replicate pilot
projects in other areas of their state, and maintain the projects
beyond the three year grant period. This paper will explore the
development of the technical assistance model based on a
knowledge transfer framework, the methods used to support
the grantees, and the impact upon the grant efforts measured
through regular feedback methods and the proportion of
grantees meeting the grant requirements.
Study Design: The study relies on the documentation of
strategies and activities and their outcomes through a webbased technical assistance tracking tool, grantee semi-annual
reports, semi-annual federal project officer grant update calls,
and notes from TA events.
Population Studied: The population studied are the AoACMS Aging and Disability Resource Center grantees awarded
in 2003 (12 states), 2004 (12 states) and 2005 (19 states).
Principal Findings: The knowledge transfer framework uses
multi-faceted, yet highly coordinated, approach to address
both immediate and longer term needs of technical assistance
(TA) recipients. Reinforcement learning plays a key role in
that it encourages information exchange among TA recipients,
which is an ongoing process of building expertise by
leveraging the knowledge gained from previous support
activities. TA recipients can build expertise through two levels
of knowledge support: 1) tailored (i.e., needs assessment and
assistance plans, teleconferences, on-site support, one-on-one
training); and 2) standardized (i.e., group trainings, practical
research synthesis and Web site content, teleconferences).
The TA model exhibits responsiveness, collaboration,
consultation, and a content/evidenced-base and includes the
following components: TA coordination; resource
development; documenting the learnings from earlier grantees
for the benefit of subsequent ones, sharing project resources
in an organized manner, expert consultant pool; multi-media
TA support; and dissemination. The TA model also builds in
a quality management component to ensure the responsive
and effectiveness of TA activities.
Conclusions: Based on the research to date, we conclude that
the technical assistance has been effective in furthering the
funders objectives while still allowing innovation.
Implications for Policy, Delivery, or Practice: Other
technical assistance efforts can build upon the framework for
activities and infrastructure recommendations to better assist
new and ongoing initiatives.
Primary Funding Source: Administration on Aging
●An Employer Initiative to Increase Use of Preventive
Health Care Services
Susan Busch, Ph.D., Colleen L. Barry, Ph.D., Sally Vegso, Jody
Sindelar, Ph.D., Mark R. Cullen, M.D.
Presented By: Susan Busch, Ph.D., Assistant Professor,
Health Policy, Yale University, PO Box 208034, New Haven,
CT 06520; Tel: 203-785-2927; Fax: 203-785-6287;
Email: susan.busch@yale.edu
Research Objective: Alcoa, a multi-site aluminum producer
with almost 50,000 employees in the U.S., and an annual
health benefit burden of approximately 800 million dollars,
has invested in a broad-based strategy to improve health
through strategic interventions to promote a healthier
workforce. In an effort to increase rates of preventive health
care use, a new health and welfare benefits program was
introduced in January 2004. This program had two
components. First, cost-sharing on preventive care services
(e.g., routine and gynecological physicals, immunizations,
mammograms, and well baby/child visits) was reduced to
zero, and these services were exempt from plan deductibles.
This change applied to both employees and their dependents.
Second, employees, but not dependents, were given a $100
flexible benefit card to pay for other out-of-pocket medical
expenses if they completed a health questionnaire and had a
routine physical. The objective of this research is to describe
the adoption and evaluate the impact of these initiatives.
Study Design: Outpatient claims data are used to examine
preventive care utilization for one year pre and one year post
program implementation. To disentangle the effect of the
reduction in cost sharing and the $100 flexible benefit card, we
examine whether the effects differ between the employees and
their dependents (spouse), with this difference representing
the effect of the flexible spending bonus. We also examine
these effects separately for hourly and salaried workers, and
for other subgroups of employees.
Population Studied: Alcoa employees and their dependents.
Principal Findings: Changes to cost sharing and financial
incentives had little impact on rates of use of preventive care
services among Alcoa employees and dependents.
Conclusions: While few differences in use of preventive care
due to the Alcoa initiatives were detected, qualitative follow-up
interviews conducted suggest that the company may need to
more effectively promote these benefits with enrollees. Rates
of preventive care use were already higher among Alcoa
employees and dependents at baseline compared with the
general population, suggesting more direct outreach efforts
may be needed to further expand use.
Implications for Policy, Delivery, or Practice: Rates of
preventive health care in the United States are low and the
health system has been criticized for emphasizing technologyintensive procedures. Two government initiatives make clear
preventive care recommendations based on scientific evidence
(USPSTF, CDC Guide to Community Preventive Services).
Adoption of these recommendations by large employers, who
shoulder a substantial burden of the cost of poor health in
midlife, has varied. Persuading employers and insurers to
focus on preventive care is a challenge because the benefits
often accrue in future years. Due to its low turnover rate,
Alcoa may have greater incentive to develop programs to
encourage use of these services than other employers.
Primary Funding Source: No Funding
●State-Focused Health Care Quality Improvement:
Translating Research from the National Healthcare Quality
Report into State Action
Ernest Moy, M.D., M.P.H., Rosanna Coffey, Ph.D., Dwight
McNeill, Ph.D., Karen Ho, MS, Craig Hunter, MS
Presented By: Ernest Moy, M.D., M.P.H., Director, National
Healthcare Quality and Disparities Reports, Center for Quality
Improvement and Patient Safety, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20852;
Tel: (301) 427-1329; Fax: (301) 427-1341;
Email: emoy@ahrq.gov
Research Objective: To translate the findings of the National
Healthcare Quality Reports (developed by the Agency for
Healthcare Quality and Research (AHRQ)) so that local
groups supported by State leaders will take action to improve
health care quality based on the evidence.
Study Design: Data related to health care quality that could
be obtained from large national data sets with specific
information at the State level have been amassed, analyzed,
and included in the National Healthcare Quality Report, now
in its third release. While available, State-level information is
buried among hundreds of tables. This series of derivative
studies and products repackaged these data from the
perspective of State leaders, added insights from the research
literature, and developed plans for actions that States could
take. Now, AHRQ will support a small number of States to
take advantage of this evidence and will guide State leaders in
initiating or re-invigorating health care quality improvement
programs.
Population Studied: The population studied is people who
receive health care in each of the States, with respect to the
quality of their health care across States.
Principal Findings: This work developed a State-led model of
quality improvement, based on quality improvement in
manufacturing and health care; the model focuses specifically
on the State’s role. This work also includes several products
that AHRQ has developed to assist States in this role:
• A newly designed State Snapshot on the NHQR—a Web
site with performance meters and composite measures of
health care quality for each State compared to the nation and
to the region, with drill-down ability to individual quality
measures. • A comprehensive guide and workbook for States
on how to initiate and lead an asthma care quality
improvement program. • A similar guide and workbook for
States on diabetes care quality improvement. AHRQ with
other Federal partners is now embarking on a program for
supporting States to initiate or enhance quality improvement
in their State and to evaluate the results of those efforts.
Conclusions: There is tremendous variation in health care
quality provided to people who seek health care in different
States. No one State excels in all types or settings of health
care. This body of work provides tools and plans for analyzing
quality and implementing improvements and evaluating the
change in the quality of health care across the States.
Implications for Policy, Delivery, or Practice: Translating
research into practice is essential to improving health care
quality in the United States. The 2005 National Healthcare
Quality Report shows that the greatest gains in quality
improvement have been in areas where concerted efforts have
been directed at quality improvement—patient safety. The fact
that variation across the States is wide and that QI efforts
have shown payoffs argues for targeted attention to the States
and the role they can play in implementing quality
improvement programs across the spectrum of diseases and
treatments. While most health care quality improvement
efforts have focused on changing provider awareness and
management of their patients’ diseases, States have an
important role to play. States can assume a leadership role in
convening partners, setting goals and designing interventions
with partners, encouraging change, and assessing the impact
through careful measurement, data analysis, and evaluation.
Primary Funding Source: AHRQ
●Evidence and Organizational Decision Making: Never the
Twain Shall Meet?
Thomas Rundall, Ph.D., John Hsu, M.D., Ph.D., Mark Gibson,
Ph.D., Pam Curtis, Ph.D., Peter Martelli, B.A., Julie
Schmittdiel, Ph.D., Estee Neuwirth, Ph.D.
Presented By: Thomas Rundall, Ph.D., Professor, Health
Policy and Management, University of California, Berkeley, 416
Warren Hall, Berkeley, CA 94720-7360; Tel: (510) 642-4606;
Fax: (510) 643-6981; Email: trundall@berkeley.edu
Research Objective: There are few studies of health
organization managers’ use of evidence in decision making.
We queried managers of health-related organizations about
their definition and use of evidence when making strategic
management decisions.
Study Design: In a qualitative study, we convened four peerto-peer focus groups to assess perceptions of high-priority
decisions, current levels of research evidence use,
characteristics of useful evidence, organizational barriers and
facilitators to using evidence, and recommended methods for
communicating evidence. The moderator recorded major
themes. Two researchers recorded all comments and
compared notes with meeting audiotapes. Using content
analysis, two researchers independently coded participant
comments. Coders initially agreed on 72.1% of codes, then
resolved discrepant codes. The investigators categorized the
codes into themes.
Population Studied: Thirty-two senior decision makers from
26 public and private organizations located in the eastern,
mid-western, and western regions of the United States.
Principal Findings: Managers reported five categories of
“high priority” management issues: 1. purchasing to improve
quality and reduce costs; 2. organization and delivery of
patient care to improve quality and reduce costs; 3.
organizational sustainability; 4. benefit design and coverage; 5.
workforce recruitment, development, and retention. Managers
reported little use of and demand for research evidence when
making decisions. Q: Does the organization use evidence to
address these management problems? Sadly, I think mostly
no. Their definitions of evidence differed from commonly
accepted scientific definitions, and emphasized colloquial,
experience-based, and tacit knowledge, e.g. use of peers,
consultants, vendors, and personal experience as sources of
evidence. Some managers reported using researchers as
expert consultants, but there was little reported use of
published research to inform decisions. Managers reported
numerous barriers to evidence use, including the belief that
most research evidence was not helpful for organizational
decision making Q: For the vast majority of questions I have, I
have found the answers are not out there. Research is not
being done in a way that answers my questions. Q: There is a
disconnect between what’s going on in academic centers and
those who are working. Even when relevant research evidence
is available, managers find it too time consuming to locate,
read, and interpret. Q: One of the things we struggle with is
having concise information, not 300 pages of a report. Among
the criteria managers use to assess the usefulness of evidence
are timeliness, accessibility, transparency, and the extent to
which it explicitly identifies actionable implications.
Conclusions: There is a substantial gap between health
services decision makers and the research community.
Decision makers rarely report using research evidence and
instead rely on other types of information such as peers with
experience. Decision makers also perceive that existing
research does not meet their needs, both in content and
accessibility.
Implications for Policy, Delivery, or Practice: Changes in
the type of research conducted, method of knowledge transfer,
and organizational decision making practices could help
bridge the gap between users and producers of health services
research. Potential strategies include: refocusing research on
problems of importance to managers; reporting evidence
more effectively; developing an evidence clearinghouse;
increasing web-based access; and training health managers in
evidence-based decision-making techniques.
Primary Funding Source: AHRQ
●How Policy-Makers View Evidence: Lessons from The
Synthesis Project.
Claudia Williams, MS, David C. Colby, Ph.D.
Presented By: Claudia Williams, MS, Principal, AZA
Consulting, 305 Buxton Road, Falls Church, VA 22046;
Tel: (571) 641 3030; Fax: (360) 237-0307;
Email: cwilliams@azaconsult.com
Research Objective: To determine how policy-makers use
health policy research evidence and asess demand for
Synthesis Project products.
Study Design: We conducted structured in-depth interviews
with state and federal policy-makers, researchers and research
translators and an on-line survey to assess reactions to
Synthesis products.
Population Studied: Federal policy-makers.
Principal Findings: Federal policy-makers say they need
evidence that helps them understand problems and
developments as well as to answer specific policy questions.
Information and evidence that fails the “so what” test will not
be used. Policy-makers and their staff want to reach their own
conclusions about research findings. While summaries are of
great use, they should enable the user to evaluate and judge
the weight of the evidence, learn about methodologies and
compare results across authors. More technical information
can be separated out, so that users can use this information
as a reference. Since policy-makers are in informationoverload, there is much good research and evidence that is
never used. One key strategy is to organize, structure and
make sense of information, putting it into understandable
frameworks. Another is to make research reports more visual
and skimmable, leading with conclusions and telling a story. A
third strategy is to synthesize bodies of evidence, rather than
presenting a single piece of research. Policy-makers also point
to the fact that certain policy decisions—often big ideological
questions (should we expand coverage and should we do it
through tax incentives) —may not be answered or addressed
through better information. Discussions about these issues
tend to be philosophically grounded, not information and data
grounded, debates. Finally, policy-makers often use people,
not paper, to gather information. The most important
implication is that researchers need a way to communicate
more directly with policy-makers, using channels policymakers use. Examples of policy materials from the Synthesis
Project will be used to illustrate these points.
Conclusions: Findings point to several important strategies
for sharing evidence with policy-makers: (a) Evidence for
policy-makers should be structured around and driven by
policy questions; not the intricacies of the research
methodologies; (b) Evidence should be presented in a way
that helps organize and manage the information; addressing
rather than exacerbating information overload; (c) Synthesized
evidence should not mask important details on the approach,
methodologies and bias of the underlying evidence; (d)
Certain policy questions are not amenable to evidence; (e)
Policy researchers need to communicate directly with policymakers on their own or through intermediaries.
Implications for Policy, Delivery, or Practice: Researchers
need a new set of skills and approaches to communicate
evidence to policy-makers. Active engagement with the policy
audience—starting with identifying the research questions to
be studied—is critical to ensure that research evidence is
relevant and useful.
Primary Funding Source: RWJF
Related Posters
Translating Research Into Policy & Practice
Poster Session A
Sunday, June 25 • 2:00 pm – 3:30 pm
●Improving HIV Screening with Rapid Testing and
Streamlined Counseling
Henry Anaya, Ph.D.
Presented By: Henry Anaya, Ph.D., Research Scientist, US
Department of Veteran's Affairs, 11301 Wilshire Blvd. 111G, Los
Angeles, CA 90073; Tel: 310-478-3711 x48488;
Email: henry.anaya@va.gov
Research Objective: Testing for HIV has been shown to be
cost effective in unselected general medical populations, yet
rates of testing among those at risk remain far below optimal,
even among those with regular primary care. The specific
aims of this project are: •To determine whether nurse-based
referral for traditional HIV testing and counseling will improve
screening rates compared to current testing procedures.
•To determine whether nurse-based rapid testing with
streamlined counseling improves screening rates more than
nurse-based referral for traditional testing and counseling
alone.
Study Design: A parallel-group, controlled study was
conducted in the primary/urgent care clinics of the West Los
Angeles VA. Eligibility was based on same-day appointment;
age (18-65); no prior HIV test in past year; unknown HIV
status. One hundred sixty six patients were randomized to one
of three screening models: Model A: patients urged to discuss
testing with their physician (control). Model B: nurses offered
traditional counseling/testing. Model C; nurses offered
streamlined counseling/rapid testing. Interventions were
performed by nurses in addition to their regular clinic duties.
Population Studied: Veterans
Principal Findings: Model A: 22 patients (40.7%) had test
ordered; Model B: 48 (84.2%) had test ordered; Model C: 51
(92.7%) had test ordered. Of 22 patients in Model A with a
test order, 9 (40.9%) received results; of 48 patients in Model
B with test order, 25 (52.1%) received results; of 51 patients in
Model C with test order, 46 (90.2%) received results.
Conclusions: Results show that both interventional models
will likely result in higher screening rates than traditional HIV
testing models in primary care.
Implications for Policy, Delivery, or Practice: HIV rapid
testing has been shown to be an effective means by which to
convey results to patients, which is especially salient given the
approximately 300,000 persons in the US alone who are
unaware of their HIV-positive status. Increased rates of
testing could lead to earlier identification of disease, increased
treatment and reduced morbidity and mortality. Reduced
intensity of counseling might free staff resources. As the VA is
the largest HIV care provider in the US, it would be beneficial
for VA policymakers to consider implementing rapid testing
on a regular basis.
Primary Funding Source: VA
●Propensity Score Matching with More than Two
Categories
Onur Baser, MA, MS, Ph.D.
Presented By: Onur Baser, MA, MS, Ph.D., 777 Eisenhower
Parkway, Ann Arbor, MI 48108; Tel: 734-332-4246;
Email: onur.baser@thomson.com
Research Objective: We applied the extension of propensity
score methodology that allows for estimation of average
causal effects with multi-valued treatment.
Study Design: The methodology requires three steps: 1.
Estimating propensity score with multinomial or nested logit
2. Estimating the conditional expectation and 3. estimate
average respond treatment by calculating average of
conditional expectation averaged over the distribution of the
pre-treatment variables.
Population Studied: The Market Scan private insurance data
base was used in this study which based upon asthma
individuals whose health care was provided under a variety of
fee-for-service (FFS), fully capitated and partially capitated
health plans , including exclusive provider organizations,
indemnity plans.
Principal Findings: Treatment is divided into three
categories: (a) Controller Only (b) Reliver Only (c) Reliever
and Controller. These three categories is matched with Control
group using multionomial logit. Pre-period demographic and
clinical factors are used as a covariate. Conditional
expectations are calculated and applied as a weight to
estimate average treatment effect among asthma patients.
Reliever and Controller patients have the highest treatment
effect whereas controller only patients have the lowest effect.
Conclusions: Multi-valued treatment is common in
pharmacoeconomical research and extension of propensity
score matching to cover multi-valued treatment is
straightforward and easy to apply.
Implications for Policy, Delivery, or Practice: Policy
researchers should keep the propensity score mathcing as an
option rather than swithcing multivariate analysis.
Primary Funding Source: No Funding
●Estimation Power of Different Comorbidity Indexes
Onur Baser, Judy Stephonson
Presented By: Onur Baser, 777 Eisenhower Parkway, Ann
Arbor, MI 48108; Tel: 734-332-4246;
Email: onur.baser@thomson.com
Research Objective: Health care expenditures are strongly
influenced by overall illness burden. Appropriate risk
adjustment is required for correct policy analysis. We
compared three risk adjustment methods: Charlson (CHS),
Elixhauser (ELX) and Chronic Disease Score(CDS) in terms of
their estimation power for analysis of health care expenditure.
Study Design: Total 7 models are considered. Using same
demographic factors, models are separated by index variables:
1. CHS only 2. ELX only 3. CDS only 4. CHS and ELX 5. CHS
and CDS 6. CDS and ELX 7. CHS, ELX and CDS. A generalized
linear model with log link and gamma family is used to
estimate the model. BIC, AIC and log likelihood scores are
calculated across different models to see which model is best
fit. Average squared prediction error (ASPE) are considered to
asses the estimation power of these indexes. We randomly
divide the sample into two parts: training subsample and test
subsample. The models were estimated for the training
subsamples, and ASPE was calculated for the test samples.
Population Studied: Market Scan data were used to estimate
total health care expenditures of migraine patients treated by
triptan
Principal Findings: After certain inclusion and exclusion
criteria 43776 migraine patient with triptan used created our
analytic samples. “Charlson”, an older and common risk
adjustment method, performed the poorest in terms of
estimation power. In a single index models (model 1-3)
Elixhauser, in a double index models ( model 4-7) Charlson
and Elixhauser performed the best. With detail analysis of
multicollinearity analysis using variance inflation factor we fail
to find any multicollinearity between three measures. Overall
best performance found with model seven where we used
three measures in the same model.
Conclusions: When we analyze three different risk adjustment
methods, we found that each one of them measures different
risks and can be used together in a single model. Using only
Charlson comorbidity index would be misleading.
Implications for Policy, Delivery, or Practice: Several
comorbidity measures are intended to control for different
effects. Ignoring for the sake of multicollinearity may result in
bias results.
Primary Funding Source: No Funding
●The Performance of Bootstrapping in Discrete Choice
Models
Onur Baser
Presented By: Onur Baser, 777 East Eisenhower Parkway, Ann
Arbor, MI 48108; Tel: 734-913-3897;
Email: onur.baser@thomson.com
Research Objective: Discrete choice models are widely used
in pharamacoeconomics. Estimation of probability of certain
treatment or estimation of inpatient, outpatient, office visits
are common areas where we see the application of discrete
choice models. Bootstrapping-if correctly applied- is very
useful tool for these models because small sample
distributions of the dependent variables are not known. In this
paper, we will show how to apply bootstrapping to have
consistent and efficient estimators under discrete choice
models.
Study Design: Four common boostraping techniques
analyzed: Paried, non-parametric, parametric and wild
bootstrapping. Bootstrapping improves the performance of
the inference in all commonly used discrete choice
estiamators-logit, probit etc- in health research. Since almost
all models are consistent under parametric assumptions,
parametric bootsrapping should be used. Extension to
parametric bootstrap for linear regression to parametric
discrete choice models are presented: Let be the probability
that the binary dependent variable y=1. Then for each
application we choose y*, which is new independent variable
for each bootstrap, from Bernoulli distribution with probability
of success given by
Population Studied: The Market Scan private insurance data
base was used in this study which based upon analytic sample
of 36341 asthma individuals whose health care was provided
under a variety of fee-for-service (FFS), fully capitated and
partially capitated health plans , including exclusive provider
organizations, indemnity plans
Principal Findings: We estimate hospitalization for FFS and
non FFS asthma patients. The dependent variable was 1 if
patient is ever hospitalized for the two year follow up period
and 0 other wise. Logit models are selected depending on the
distribution of the dependent variable. Pearson chi-square
goodness of fit test (p=0.3742) and Hosmer and Lemeshow
test (p=0.2904) suggest that the model fits well. Treatment
patterns have no significant effect on hospitalization after
controlled for demographic and clinical factors. Severity of
patient proxied by #3 digit ICD-9 codes, however, have
positive and significant effect on hospitalization. We could not
see this significant effect if we chose paired, non-parametric or
wild bootstrapping as way way to bootstrap standard errors.
Conclusions: Despite the obvious benefit of bootstrapping in
discrete choice models, the bootstrap should not be used
blindly. Once the model is estimated under parametric
assumptions as in logit or probit models, deviations of the
assumptions for bootstrapping will yield inefficient estimators.
Implications for Policy, Delivery, or Practice: Discrete
models are common in health service research. Bootstraping
provide excellent tool for researchers to determine the
significance of the estimates of interest.
Primary Funding Source: No Funding
●Evaluating a Community-Based Participatory Intervention
to Facilitate Mental Healthcare in Rural Missouri
Dean Blevins, Ph.D., Rene McGovern, Ph.D., Bridget Morton,
RN
Presented By: Dean Blevins, Ph.D., Research Health Scientist,
Department of Psychiatry, Central Arkansas Veterans
Healthcare System & University of Arkansas for Medical
Sciences, 2200 Fort Roots Drive (152/NLR), North Little Rock,
AR 72114; Tel: 501-257-1102; Fax: 501-257-1718;
Email: BlevinsDean@uams.edu
Research Objective: The proposed presentation will focus on
the lessons learned in developing the methods to evaluate the
collaborative nature between academic researchers and their
community partners. Specifically, the authors will discuss the
use of Naylor’s model of community-based participatory
research and propose a modified process.
Study Design: Naylor et al.’s (2000) model of communitybased participatory research was adopted to structure the
interviews across five dimensions of such collaboration.
Sixteen collaborating partners were interviewed by an
experienced qualitative interviewer not associated with the
ElderLynk program. The Principle Investigator and Project
Coordinator additionally provided feedback on attempts to
facilitate the participation of community partners on each
dimension. Rating scales were developed for each of these
dimensions to assess the degree of collaboration and followed
by probe questions to explore in-depth type and success of the
intervention’s implementation. These data were combined
and analyzed to classify the type of collaboration that
occurred. Responses given to the follow-up probe questions
of the perceptions of the community partners were compared
to responses from the central project staff.
Population Studied: Sixteen community partners in the
initiative and the principle research team.
Principal Findings: Respondents almost unanimously
believed the program was successful in achieving its
objectives, especially given a host of barriers. Rating scales
suggested overall satisfaction with the degree of collaboration,
but were difficult to interpret without the follow-up probe
questions. Although this process was similar to Naylor’s
original methodology, significant modifications were
necessary, As the program developed and changed over
time, the collaborative approach adopted laid the foundation
for the grant-funded program to transition into a non-profit,
self-sustaining organization, with the evaluation process itself
influencing the outcomes.
Conclusions: ElderLynk began as a unique program that
evolved to enhance its implementation through an active
exchange between researchers and community partners.
Many lessons were learned through this process that will be
particularly important to informing community-based
participatory research interventions in rural areas, how
collaborative partnerships can successfully be structured, and
how such initiatives can effectively be evaluated.
Primary Funding Source: CSAT
●The Care Transitions Intervention: Translating Research
into Practice
Eric Coleman, M.D., M.P.H., Carla Parry, Ph.D., MSW, Sandra
Chalmers, M.P.H., Sung-joon Min, Ph.D.
Presented By: Eric Coleman, M.D., M.P.H., Associate
Professor, Health Care Policy and Research, University of
Colorado Health Sciences Center, 13611 E. Colfax Ave., Suite
100, Aurora, CO 80011; Tel: (303) 724-2456; Fax: (303) 7242486; Email: Eric.Coleman@uchsc.edu
Research Objective: Patients with complex care needs who
require care across different health care settings are vulnerable
to experiencing serious quality problems. Because of
inadequate coordination and communication among
practitioners, these patients are often placed in the position of
assuming a major role in their care transitions without
adequate support or tools. The objectives of this study were to
test whether an intervention designed to encourage patients
to assert a more active role during care transitions can reduce
re-hospitalization rates and then translate the research into
practice.
Study Design: Randomized Controlled Trial. Between
September 1, 2002 and August 31, 2003, patients were
identified at the time of hospitalization and randomized to
either receive the intervention or usual care. Intervention
subjects received (1) tools to promote cross-site
communication; (2) encouragement to take a more active role
in their care and assert their preferences; and (3) continuity
across settings and guidance from a nurse "Transition
Coach." Rates of post-discharge re-hospitalization were
measured at 30, 90, and 180 days.
Population Studied: A large integrated delivery system
located in Colorado. Community-dwelling adults age 65 years
and older admitted to the study hospital with one of eleven
selected conditions (N=750).
Principal Findings: Intervention patients had lower postdischarge re-hospitalization rates at 30 (p=0.05), 90 (p=0.03),
and 180 days (p=0.14) than control patients. Similarly,
intervention patients had lower re-hospitalization rates for the
same condition that precipitated the index hospitalization at
30 (p=0.04), 90 (p<0.01), and 180 days (p<0.01) than control
patients. Mean 90-day hospital costs were significantly lower
for intervention patients ($2058 vs. $2546, P=0.03).
Conclusions: Coaching chronically ill older patients and their
caregivers to ensure that their needs are met during care
transitions may reduce the rate of subsequent rehospitalization.
Implications for Policy, Delivery, or Practice: With the
support of the John A. Hartford Foundation, the Care
Transitions Intervention has been translated into practice into
6 leading health care systems and partially translated into
another 4 health care systems. The primary strategies used to
disseminate the intervention including defining the business
case, leveraging national efforts to create demand, and
generating attention using previously developed tools, will be
discussed and key lessons learned to date will be shared.
Primary Funding Source: John A. Hartford Foundation and
the Paul Beeson Faculty Scholar in Aging Research/American
Federation for Aging Research
●Communication Failure and Patient Safety
Elizabeth Dayton, M.A., Kerm Henriksen, Ph.D.
Presented By: Elizabeth Dayton, M.A., Jr Service Fellow, US
Dept of Health and Human Services, Agency for Healthcare
Research and Quality, 540 Gaither Road, Rockville, MD 20850;
Tel: (301) 427-1320; Email: edayton@ahrq.gov
Research Objective: A significant body of research reveals
that poor communication is a leading cause of adverse events
in health care. The majority of patients today are cared for by
a loosely coordinated mix of providers and specialists, and
unless these practitioners communicate clearly about
diagnoses, patient needs, and procedures, the potential for
adverse events is amplified. Despite the seemingly secondnature quality by which most communication occurs,
communicating clearly to construct common understanding
poses a serious challenge in health care.
Study Design: Synthesis of literature from the social,
cognitive, and organizational sciences applied to issues of
patient safety in health care.
Population Studied: Communication among health care
providers.
Principal Findings: We will first discuss the healthcare
literature that documents the seriousness of the problem, and
then present a model of basic components and processes
from the communication literature that portrays how
communication can break down at an elementary level.
Breakdowns begin with basic exchanges between two people
in which messages are encoded and decoded. Further
difficulties become apparent in teasing apart more complex
social interactions. We will describe the complex mosaic of
social, team, and organizational variables that dynamically
interact to shape the context in which basic communication
exchanges can be stifled or facilitated. Understanding how the
components and processes of communication can break
down and how the complex web of social and organizational
interactions can further inhibit communication is a necessary
step toward improvement.
Conclusions: When failed communication has the potential
to harm patients, additional compensatory mechanisms are
needed that efficiently structure the communication to reduce
ambiguity, enhance clarity, and send an unequivocal signal
that something is wrong requiring further action. In most
high-risk, high reliability industries, where there is a potential
to harm people, expensive equipment, or the environment,
communication is not left to chance but takes a purposefully
designed or structured form. This is currently not the case in
health care. However, we will conclude with some examples
of structured communication – reads-backs, SBAR, and critical
assertions – derived from other high risk industries and
currently implemented in a number of clinical settings that
recognize the need to more effectively design critical
communications.
Implications for Policy, Delivery, or Practice: These findings
are highly applicable to improving patient safety. By drawing
from the wealth of literature in communication, health care
delivery may far better avoid adverse events.
Primary Funding Source: AHRQ
●Increasing Medicaid Recipients' Enrollment in EmployerBased Health Care with State Subsidized Premium
Assistance
Jean Du, Ph.D.
Presented By: Jean Du, Ph.D., Manager, Program Evaluation,
Department of Social and Health Services, State of
Washington, P.O. Box 45536, Olympia, WA 98504-5536; Tel:
(360)-725-1033; Fax: (360)-586-9548; Email: dujj@dshs.wa.gov
Research Objective: High health care cost has driven more
and more employers to reduce employee health benefits in the
form of higher premiums, cost sharing, and/or greater
restrictions on eligibility. Consequently, the ranks of the
uninsured grew regardless of expanded Medicaid coverage for
the poor, with expenditures increasingly becoming
unsustainable for many states. This research intends to
explore the feasibility of increasing take-up rate of employerbased insurance among Medicaid recipients by providing
state subsidized premium assistance and assess the costbenefit of this approach. Research questions include: How
many Washington Medicaid recipients may be eligible for but
are not enrolled in employer-based health insurance? To what
extent can state transition these recipients to employer-based
health care through cost-effective premium assistance? What
are the major obstacles in transitioning Medicaid recipients to
employer-based health care?
Study Design: To answer the research questions, we
launched a one-year, small-scale research pilot project. We
started with nalyses of employment patterns of a subgroup of
Medicaid recipients in year 2004, primarily non-elderly
recipients or parents of recipient children. We matched
recipient data with the state’s wage records to identify
employment, including industry, size of employer, and hours
of work. Upon identification of who worked where, we began
targeted outreach activities. These efforts were necessary to
identify the availability, benefit structure, and employee
portion of the cost of employer-based coverage. Where we
identified recipients eligible for but were not enrolled in
employer plans, we’d assess the cost effectiveness of
providing state subsidized premium assistance to help them
take up employer-based coverage. Recipients enrolled in
employer-based insurance would primarily use employerbased health care while maintaining their Medicaid eligibility
and benefits they were otherwise entitled to.
Population Studied: Medicaid recipients and/or parents of
Medicaid recipient children.
Principal Findings: Of the selected cohort of non-elderly
Medicaid recipients and/or parents of recipient children:
Between 48% and 53% were employed at any time. Of those,
75% were employed with the same employer for at least two
consecutive quarters, and 48% were with the same employer
year round; About 27% of the employed recipients/parents
were estimated to be eligible for but were not enrolled in
employer-based health insurance; Preliminary pre- and postutilization analysis showed that transitioning these recipients
to employer-based insurance with state subsidized premium
assistance reduced Medicaid costs for these recipients by
30%-35%; Challenges we encountered included 1) A relatively
short enrollment time often prevented us from enrolling
eligible recipients in employer-based insurance; 2) Low levels
of recipient response and/or cooperation.
Conclusions: The state can successfully transition Medicaid
recipients to employer-based health coverage through costeffective premium assistance. Such transitions help increase
Medicaid recipients’ usage and attachment to employer-based
health care as well as reduce Medicaid costs.
Implications for Policy, Delivery, or Practice: This pilot
research has made a significant policy impact in that the
Governor has recently announced in her budget proposal to
expand the operational aspects of the project with additional
program staff and resources.
Primary Funding Source: Other Government
●A Framework to Fund and do Syntheses for Managers
and Policy-makers
Diane Gagnon, Ph.D., Nick Goodwin, Ph.D., Susan Law,
MHSc
Presented By: Diane Gagnon, Ph.D., Senior Program Officer,
Granting & Commissioning, Canadian Health Services
Research Foundation, 1565 Carling, Ottawa, K1Z 8R1; Tel:
(613) 728-2238; Fax: (613) 728-3527;
Email: diane.gagnon@chsrf.ca
Research Objective: To develop a framework for conducting
and commissioning research syntheses building on
international evidence and best practice. To incorporate
design features and methods through which decision makers
are best informed, and the research is most relevant to
managers and policy makers in healthcare.
Study Design: Multiple/sequential activities: a- review of
literature; b- three research teams investigated unresolved
issues in methods of synthesizing evidence useful for
managers and policy-makers; c- international forum with five
expert panelists and 75 participants discussed outstanding
issues; d- survey of nine international funding agencies; eworkshop with 48 international experts to establish best
practice guidance in conducting and funding syntheses; f- two
workshops (UK and Canada), with managers and policymakers to further develop the framework.
Population Studied: International scientific and grey
literature in the field of methods of synthesis; researchers,
funders, managers, and policy makers identified as
stakeholders in the synthesis process.
Principal Findings: a- There is no common definition of
synthesis, but most agree that the underlying objective is to
provide health system guidance. b-The primary purpose of a
synthesis (the nature and type of health system problem being
addressed) is the key element that frames the synthesis
process. An important distinction is between ‘knowledge
support’ - to summarize evidence for general applicability –
and ‘decision support’ – requiring additional considerations to
reach a specific decision in a particular context, which may
involve deliberative processes to determine
implications/consequences of alternate decisions related to
policy/practice. c- Distinct iterative stages are proposed for
policy and management-relevant syntheses. The extent to
which syntheses contribute to knowledge support is
dependent on effective interface between research and
practice throughout the process. d- Manager and policy-maker
involvement is crucial for decision support. The level and type
of involvement amongst researchers, funders and decision
makers may, and likely should, vary for each stage. fTransparency to avoid bias is key, especially when trying to
balance relevance with science, for decision support. g- The
results are of interest to different audiences for different
reasons; products and dissemination activities should be
tailored appropriately. h- The science of syntheses is at an
infancy stage. There is a need to further develop and evaluate
this framework as it applies to different types of syntheses and
contexts.
Conclusions: The creation of an overall framework, or set of
guiding principles, for conducting and commissioning
syntheses is both feasible and desirable, in terms of
establishing consistency of conceptual and practical issues
within the international research and funding community; also
to ensure consistency of expectations for relevance, process
and outcome amongst healthcare decision makers.
Implications for Policy, Delivery, or Practice: Managers and
policy makers are likely to more readily access and use
relevant research and evidence to inform their decisionmaking if they become active partners in the process of
synthesis production itself. This requires a new and more proactive paradigm to the funding and operationalisation of
research syntheses comprising a closer and more coordinated
relationship between funder, research and user via the
creation of effective decision-support mechanisms.
Primary Funding Source: Canadian Health Services Research
Foundation; NHS Service Delivery and Organisation R&D
Programme; Canadian Institutes of Health Research.
●Using Informatics to Rapidly Build the Evidence Base for
Improved Program Management and Accountability
Susan Griffey, DrPH, BSN, Katrina Hedlesky, BA, E. Allen
Kendall, MS, Souleymane M. Barry, MBBS, Jeff McCartney, MS
Presented By: Susan Griffey, DrPH, BSN, Senior Vice
President, Global health and Development Strategies, Social &
Scientific Systems, Inc., 8757 Georgia Avenue, 12th Floor,
Silver Spring, MD 20910; Tel: (240) 463-2653; Fax: (301) 6283001; Email: sgriffey@s-3.com
Research Objective: To identify successes resulting from
technological advances promoting instant access to data and
results from SSS’ decade of experience applying portfolio
management with US and global governments and donor
agencies
Study Design: A synthesis review to identify the best practices
and models of portfolio management
Population Studied: Nine projects from state, federal and
international governments and agencies
Principal Findings: Successes of SSS’ portfolio management
(PM) model range from full-service PM where SSS staff and
resources are partnered with clients resulting in internal and
external accountability (portfolio reviews and analyses and
reports) to focused PM services such development and
implementation of tracking and reporting systems for
interventions such as combating HIV/AIDS: • PM with the
U.S. Agency for International Development (USAID) produced
an objective and external comprehensive mid-term HIV/AIDS
Accomplishments Review for USAID, aggregating data from
over 2,800 HIV and AIDS activities in 85 countries from the
web-based inventory SSS developed, from which analyses and
a synthesis of lessons learned in the first 5 years of USAID’s
10-year strategy were produced. • Development of a
coordinated and unified tracking and reporting system for
State Department’s Office of the Global AIDS Coordinator
(OGAC), ensuring that all USG agencies working in 20 focus
countries combating the AIDS pandemic can and do report
both to OGAC who then reports to the US Congress on the
AIDS earmark. Country USG teams access the web-based
secure data to manage their AIDS programs and to work
collaboratively with other country programs • A state-level
decision-support system gives continual results to a variety of
user levels from hospital decisionmakers to quality of care
officers, providing them instant results on improved
outcomes whenever they need the information. • Research PM
for researchers in AIDS prevention (microbicides) and
treatment (antiretrovirals), resulting in instant access for NIH
and USAID to research progress and findings and researchers
having a shared community of practice globally.
Conclusions: SSS’ proven PM approach is based on an
integrated program management cycle of assessment,
planning, design, implementation monitoring, and evaluation
(APDIME©). A key component is ongoing access to data on
program progress and outcomes for policymakers and
stakeholders to respond efficiently and effectively to changing
population health needs. SSS has exploited advances in
informatics, taking advantage of rapid growth and breadth of
technology. This continual and timely data access allows the
evidence base for interventions to be reinforced, refined, and
accessible for decision-making and for public accountability.
Data accessibility from standardized databases – web-based
and globally accessible whenever needed – reflects consensusbuilding on indicators and definitions for health programs and
guides all levels of healthcare services to report on common
goals, irrespective of program focus.
Implications for Policy, Delivery, or Practice: Portfolio
management based on technological solutions improves
instant data access that policymakers and program managers
need to ensure relevant interventions and provide
accountability. SSS’ global successes have demonstrated the
effectiveness of this aspect of integrated program
management. In one case of AIDS services, for example,
duplications of service populations were rapidly identified and
eliminated so that appropriate denominators could be
established and performance accurately measured annually.
Primary Funding Source: USAID, NIH, GHA
●Evaluating a Program that Translated Research to
Practice: The Case of Integrating Behavioral Health
Providers into Primary Care
Daniel Harris, Ph.D.
Presented By: Daniel Harris, Ph.D., Senior Project Director,
Institute for Public Research, The CNA Corporation, 4825
Mark Center Drive, Alexandria, VA 22311; Tel: (703) 824-2283;
Fax: (703) 824-2511; Email: harrisd@cna.org
Research Objective: Current literature suggests that
programs integrating behavioral health providers into primary
care can cost effectively enhance patient care. We assisted a
large, multi-site staff model managed care system to translate
existing research into a demonstration of such a program, and
conducted ongoing evaluation of the two-years demonstration
in order to (1) assess its implementation process,
sustainability, and outcome performance, (2) identify factors
facilitating and hindering its success, and (3) provide system
management an evidence base with which to revise it to
increase its chances of success prior to taking it wholesale
throughout the system.
Study Design: We assisted system management to translate
research into a program practice manual which also contained
explicit program goals and an implicit program logic on which
to base an evaluation of the demonstration. A cadre of
psychologists and social workers from the system’s mental
health service were briefly trained in primary behavioral health
care and introduced as “behavioral health consultants”
(BHCs) into seven primary care clinics. Using available
administrative data, project-specific primary data, interviews,
and site visits, we monitored the program’s implementation
between January 2003 and February 2004 in three successive
cohorts of clinics, and measured program performance and
impact through December 2004. Process evaluation focused
on program implementation and sustainability, fidelity, and
output at each demonstration site. Outcome evaluation
focused on effectiveness and impact on patients, providers,
and the participating clinics, and also utilized a quasiexperimental design to compare demonstration site
performance with that of matched non-demonstration sites.
Population Studied: Patients, BHCs, and primary care
providers at seven primary care clinics in a large multi-site
managed care system.
Principal Findings: The program was successfully
implemented in six sites with varying degrees of fidelity; long
term sustainability was not achieved and some
implementation issues faced by early sites continued to pose
problems for later sites despite attempts to address them.
Program output levels varied across sites, but target patient
populations were reached. Participants expressed general
satisfaction with the program although they identified issues
affecting both implementation and impact. Primary care
providers typically referred patients to BHCs more for
traditional mental health care than for the behavioral or
“health psychology” issues the program intended to address.
Program clinical and financial outcomes, and impact on
primary care and mental health utilization patterns, generally
met program goals but were less substantial than expected
and varied across sites. Clear performance advantages at
demonstration sites compared to control clinics were not
detected.
Conclusions: Successful implementation of sustainable and
effective high fidelity programs that translate research to
practice is not a given and requires much program planning
and management, a stable environment, and managers and
providers who understand and are committed to the program
logic.
Implications for Policy, Delivery, or Practice: In developing
a program that translates research to practice, managers
should develop a clear and convincing program logic to build
commitment, incorporate measurable goals and an evaluation
process into the program from the start, and focus on the
program’s environment as well as its internal operation.
Primary Funding Source: Other Government
●The Perceived Costs and Benefits of Collaboration in
Health Research
Timothy Huerta, Ph.D., Linda Peritz, Ph.D., Keith Provan,
Ph.D., Pamela Clark, Ph.D.
Presented By: Timothy Huerta, Ph.D., Research Scientist,
PHSA Research and Networks, Child and Family Research
Institute, 601 West Broadway, Vancouver, CA V5Z4C2; Tel:
604.707.6398; Fax: 604.707.6399; Email: tim.huerta@ttu.edu
Research Objective: To gain a greater understanding of the
perceived costs and benefits of collaboration in health
research.
Study Design: Survey to 68 leading tobacco control
researchers for use in a analysis studying transdisiciplinary
relationships in a nascent research network.
Population Studied: Research Scientists in Tobacco Control
Principal Findings: Literature on interorganizational networks
indicates that networks require resources and time on the part
of the participants in order to maintain their usefulness. As a
result, researchers are often put in the position of bearing the
costs of multiple memberships, while at the same time having
time constraints that limit their ability to act as a full member
in any given network. Often, this occurs within a context where
individual researchers must compete with other network
members for limited resources, which may hamper network
collaboration. For example, full participation in the network
may mean that you share information with potential
competitors for grants. Further, there is also some emerging
evidence that networks can stifle rather than enhance
creativity.
Conclusions: Using survey data collected among members of
the network, we find that individuals central to this emerging
effort experience less optimism and greater costs of
participation than those peripheral to the network, even where
such a network is in its nascent stages.
Implications for Policy, Delivery, or Practice: As networks
develop, there is a need for guidance for researchers and the
research community to more clearly understand the costs and
benefits associated with this method of knowledge generation
within science.
Primary Funding Source: NCI
transformational change and are necessary to build system
capacity and drive integration of otherwise independent and
disconnected units.
Conclusions: This paper adds to the discourse within the
literature in a number of ways. First, it offers a typology for
classifying the different types of networks found throughout
healthcare. Second, it focuses on one type of network, the
interorganizational health services delivery network, and
discusses how these collaborative networks generate both
challenges and opportunities throughout health service
delivery. There is a growing need to address the complicated
issue of implicit value and hidden costs of networked
organizations. With limited resources, collaborative efforts are
often in competition for the same resources used to provide
services directed to patients. Finally, we present a model for
knowledge exchange that argues that system-level knowledge
can be captured in the network of relationships formed by
agents within the system. Knowledge management
approaches in this arrangement become more about
relationship management and less about fact cataloguing and
capture.
Primary Funding Source: No Funding
●Intra-organizational Service Delivery Networks in the
Public Health Sector
Timothy Huerta, Ph.D., Ines Mergel, Ph.D.
●A Patient Centered Smoking Cessation Program Tailored
to Women’s needs-Using Research to Design and
Implement a new Program
Judith Katzburg, Ph.D., M.P.H., RN, Scott E. Sherman, MD,
M.P.H.
Presented By: Timothy Huerta, Ph.D., Research Scientist,
PHSA Research and Networks, Child and Family Research
Institute, 601 West Broadway, Vancouver, V5Z4C2; Tel:
604.707.6398; Fax: 604.707.6399; Email: tim.huerta@ttu.edu
Research Objective: There is a growing need to directly
address the challenges posed by an increased reliance on
networks used to enhance health service delivery and
research. Health services delivery agencies, faced with
expanding demand and constrained financial resources, have
sought the power of strategic alliances and partnerships to
address population trends and disease dynamics in a more
systemic way. Funding agencies continue to funnel more
resources into multi- or transdisciplinary research teams to
support the described challenged. Within the public health
sector, there has been an increasing reliance on
interorganizational coalitions in the form of communities of
practice and strategic alliances as a mechanism for building
system capacity, knowledge sharing and mutual support.
Principal Findings: While these organizational mechanisms
are often lauded as useful and beneficial, there is little to no
understanding on how interorganizational collaborative
networks generate both challenges and opportunities. While
most health professionals recognize the advantages of
networks, at least in a general way, and believe strongly in the
value of the collaborative process, they also clearly see the
need for evidence for efficient organizing on which to act.
Processes that help identify formal and informal leaders who
can champion change across organizational boundaries, add
to the understanding of the paths of knowledge sourcing and
transfer, trace the influence among networks of people,
identify ways to build effective linkages; or provide network
members with an understanding of their interdependent roles
and processes. This contributes to the strengthening of
effective collaborative processes. These processes are
perceived as critical to the implementation of planned system
Presented By: Judith Katzburg, Ph.D., M.P.H., RN, Health
Services Researcher, Center for the Study of Healthcare
Provider Behavior, VA Greater Los Angeles HealthCare
System, 16111 Plummer St., Sepulveda, CA 91343; Tel: 818-8917711 Ext. 5443; Fax: 818-895-5838; Email: jkatzbur@ucla.edu
Research Objective: Current smoking cessation programs
may not meet the needs of female smokers; women have less
success in quitting than men. There is little available literature
regarding tailoring a smoking cessation program to better
meet women’s needs. Our intermediate goal was to use a
consumer-driven approach to design an innovative, evidencebased model smoking cessation program. The long term goal
was to implement a more effective smoking cessation
program for women, predicated on women’s needs and
preferences.
Study Design: We used a multiphase approach to design the
new program. Phase I - Twenty-three women smokers who
attended the Veteran’s Administration Women’s Health
Program participated in one of four concept-development
focus groups to identify components of an ideal program. A
professional moderator led the audio-taped sessions. Two
researchers independently classified themes within the Ideal
Program domain, based on an initial line-by-line reading of
transcripts using standardized techniques as described by
Ryan & Bernard, 2003. Phase II - Results were analyzed and
presented to an Expert Panel at the Veterans Health
Administration in Washington D.C. This panel proposed a
program which was evidence-based and responsive to input
from the focus group participants. Phase III - Fifteen women
veterans, some of whom attended the first set of focus
groups, then participated in two concept-testing focus groups
which were moderated by a professional and audio-taped.
Based on their evaluation of the proposed program, final
revisions were made.
Population Studied: We collected data in Phase I and Phase
III from women veterans who were smokers and received VHA
Women’s Health Program services and in Phase II from
experts in the fields of smoking cessation, women’s health,
and women veteran’s health.
Principal Findings: Two key themes were generated from the
concept-development focus group discussions; Support and
Choice/Control. A wide variety of types and sources of
emotional support were discussed across groups. In addition
to support, the women also wanted choices and control in a
smoking cessation program, suggesting the need for an
individualized program. The Expert Panel designed a new
smoking cessation program for women, predicated on the
expressed desires of women in conjunction with current
evidence-based research. This menu-driven program included
five program options as well as a variety of quit and support
tools. Overall, the program was positively evaluated by the
concept-testing focus groups, resulting in minor revisions.
The program was implemented and the evaluation is planned.
Conclusions: A multi-phased, consumer-driven approach was
instrumental to the development and implementation of a
novel evidence-based model smoking cessation program
tailored to meet women veterans’ needs. Evaluation of the
program is the next step in this phased research project.
Implications for Policy, Delivery, or Practice: The
preliminary results suggest that involving likely participants
(consumers) in the development of an intervention program
has merit. Our ongoing program evaluation will help us
assess the value of this methodology for a phased program
design in implementation research. This approach may then
serve as a paradigm for developing consumer-driven
interventions or programs for other vulnerable populations.
Primary Funding Source: American Legacy Foundation
●The QI Implementation Process: Perspectives from
Providers and Managers
JoAnn Kirchner, MD, Louise E. Parker, Ph.D., Laura Bonner,
Ph.D., Elizabeth M. Bonner, Ph.D., Mona J. Ritchie, LCSW
Presented By: JoAnn Kirchner, MD, Staff Physician / Health
Services Researcher, HSR&D / CeMHOR, 2200 Fort Roots
Drive, Bldg 58 (152/NLR), North Little Rock, AR 72114; Tel:
(501) 257-1719; Fax: (501) 257-1718;
Email: kirchnerjoanne@uams.edu
Research Objective: Spread of new technologies across
healthcare organizations is a complex process whose
determinants health service researchers are only beginning to
study. Successful implementation often requires participation
of stakeholders from a broad spectrum of professional
backgrounds, skill sets, and levels within the organization.
Readiness to participate in implementation efforts may differ
substantially among stakeholder groups. Further, a variety of
individual, organizational, and cultural characteristics,
structures, and processes may differentially affect stakeholder
groups’ readiness and ability to embrace and participate in
implementation efforts. The purpose of this presentation is
two-fold. First, we describe methods we used in a formative
evaluation of the TIDES program, a VA sponsored depression
care quality improvement (QI) initiative. Second, we describe
how we applied findings from this evaluation to identify
implementation barriers and inform the TIDES QI effort in an
ongoing process. We believe that our methods and findings
are applicable to a broad range of QI improvement efforts
within behavioral health as well as in other healthcare areas.
As such we offer them as a blueprint for utilizing formative
evaluation to guide quality improvement across the healthcare
industry.
Study Design: We conducted key informant interviews with
TIDES participants concerning their experience with the
implementation process as well as their perspectives
concerning barriers to and facilitators of the quality
improvement effort. We analyzed verbatim transcripts utilizing
a grounded theory approach. To enhance coding consistency,
a two-person team coded all the relevant text, refined their
coding scheme and resolved coding differences.
Population Studied: We interviewed a purposive sample of
72 stakeholders participating in the TIDES initiative.
Informants included depression care managers involved in the
QI effort and providers and managers from three VA service
networks, five medical centers, and five intervention clinics.
Principal Findings: Stakeholders provided cogent and
practical recommendations regarding who to involve in
implementation efforts, roles and characteristics of
champions, roles for leadership and resources needed to
support QI. They also offered general recommendations for
conducting quality improvement initiatives so as to foster
initial implementation, sustainability, and spread.
Conclusions: Providers and managers can articulate specific
activities to improve the implementation and spread of
evidenced based practices though there was some variation
across stakeholder groups. This type of information is useful
on two levels. First, it can provide valuable feedback to the
specific implementation effort studied. In fact, as the TIDES
program is an on-going effort, we are able to utilize our
findings to provide timely actionable feedback to the
implementation team. Second, much of what our informants
offered have broad implications for QI implementation and
thus can inform the field in general.
Implications for Policy, Delivery, or Practice: Quality
improvement efforts within healthcare organizations are most
likely to be effective when they are supported by the total
system including all its many stakeholders. Therefore,
successful implementation necessitates broad based inclusion
of stakeholder input from diverse organizational levels. Such
input can directly inform the implementation process and
support the development of an equal partnership between
managers and providers and those initiating the QI effort.
Primary Funding Source: VA,
●Translating Research into Policy: Using Administrative
Data to Predict Future Psychiatric Hospital Utilization.
Andrew Kolbasovsky, PsyD, Leonard Reich, Ph.D.
Presented By: Andrew Kolbasovsky, PsyD, director, Mental
Health, HIP, 55 Water St, New York, NY 10041; Tel: (646) 4477231; Email: akolbasovsky@hipusa.com
Research Objective: The objective of this research is to create
a Predictive Model using only administrative data available at
the time of a member’s discharge from a psychiatric
hospitalization, to predict the amount of days the member is
likely to spend in the hospital for a psychiatric condition in the
12 months following that initial hospitalization. Statistically
significant variables are identified to predict future hospital
utilization for psychiatric conditions. The results are translated
into policies aimed at identifying members in greatest need of
mental health services earlier in order to proactively deliver
needed case management and outpatient services to improve
care and reduce the need for future hospital utilization.
Study Design: Retrospective review of data utilizing
regression modeling.
Population Studied: Plan members aged 6 and older who
were discharged from a hospital for a psychiatric condition
between 7/1/02 and 6/30/03, maintaining insurance coverage
from twelve months prior to the discharge to twelve months
following the discharge were included in the study. The initial
hospitalization during the study’s time frame is referred to as
the “index hospitalization.”
Principal Findings: Results demonstrated that a statistically
significant predictive model was created that predicted days
spent in the hospital for psychiatric conditions in the 12
months following the index hospitalization. Approximately
40% of the variance in the future number of days in the
hospital for psychiatric conditions following the index
hospitalization was explained by the variables in the model.
Statistically significant variables predicting future days in the
hospital were identified: age, Medicare insurance coverage,
number of days in the hospital for psychiatric conditions in
the twelve months prior to the index hospitalization, length of
stay of the index hospitalization, a psychotic diagnosis, and a
bipolar diagnosis.
Conclusions: Results of this study demonstrate that using
only information that is easily attainable administratively,
members likely to end up in the hospital for the greatest
amount of time in the future can be identified upon discharge
from a psychiatric hospitalization. Thus, members with the
greatest psychiatric needs can be identified proactively rather
than having to wait until a pattern of inpatient utilization has
been realized before intervening, making earlier and targeted
interventions possible.
Implications for Policy, Delivery, or Practice: The predictive
model created in this study is unique in that it explains a high
proportion of the variance yet utilizes only information that
can be obtained quickly and easily by administrative means
allowing for the practical and financially feasible application of
this model into practice in a variety of organizations. It is also
unique in that it demonstrates how research can be translated
in policies promoting best practices. Results of this study have
been translated into policy and practice in our health plan.
Using the results of the predictive model, a risk score is
calculated for each member discharged from a hospital for a
psychiatric condition. Based on this score, risk stratifications
have been created with different levels of case managementbased interventions delivered to members based on their risk
score, allowing the Plan to direct the greatest amount of the
limited available resources to members in greatest need, while
delivering targeted services of a lesser intensity to members
with less need.
Primary Funding Source: No Funding
●Prescribing Patterns Following Publication of the
Antihypertensive and Lipid-Lowering Treatment to Prevent
Heart Attack Trial (ALLHAT) in Regione Emilia Romagna,
Italy
Vittorio Maio, PharmD, MS, MSPH, Elaine J. Yuen, Ph.D.,
MBA, Kenneth D. Smith, Ph.D., Daniel Z. Louis, MS
Presented By: Vittorio Maio, PharmD, MS, MSPH, Assistant
Professor, Health Policy, Jefferson Medical College, 1015
Walnut Street, Suite 115, Philadelphia, PA 19107; Tel: (215) 9551821; Fax: (215) 923-7583; Email: vittorio.maio@jefferson.edu
Research Objective: Begun in February 1994 and ended in
March 2002, the ALLHAT study was the largest hypertension
trial ever conducted, and was designed to provide meaningful
comparisons between three widely used newer drug classes
(calcium channel blockers (CCBs), angiotensin-converting
enzyme (ACE) inhibitors, and alpha-blockers) and diuretics-standard, long standing treatment for hypertension. In March
2000, the alpha-blocker arm of ALLHAT was prematurely
discontinued because of a greater risk of cardiovascular events
compared with diuretics. In December 2002, the ALLHAT
main findings were published, recommending that thiazidetype diuretics should be preferred for first-step therapy in
uncomplicated hypertensive patients, compared with either
CCBs or ACE inhibitors. The objective of the current study was
to examine prescribing patterns for antihypertensive agents in
Regione Emilia Romagna (RER), Italy, following the
publication of the ALLHAT results.
Study Design: We studied automated pharmacy claims of
approximately 4 million RER residents between January 1,
2000 and December 31, 2003. We computed the monthly
relative percentage of filled prescriptions for six
antihypertensive classes: thiazide-type diuretics, ACE
inhibitors or angiotensin receptor blockers (ARBs), CCBs,
beta-blockers, alpha-blockers, and other-type antihypertensive
diuretics. Any combinations of these antihypertensive classes
were not included in the analysis. A stepwise auto-regressive
forecasting model was used for time series analysis. To assess
the impact of the ALLHAT guidelines on use of each
antihypertensive class, we calculated predicted relative
percentages and 95% confidence intervals for the 12 months
of 2003.
Population Studied: RER residents who received any
prescriptions for the selected six antihypertensive classes
between January 1, 2000 and December 31, 2003.
Principal Findings: During the study period, ACE
inhibitors/ARBs and CCBs had the largest relative percentages
of hypertensive prescriptions (approximately 40% and 30%,
respectively), while the relative percentages for other-type
antihypertensive diuretics and beta-blockers were roughly 12%
and 10%, respectively. Alpha-blockers and thiazide-type
diuretics accounted approximately for 4% and 1% of all
prescriptions, respectively. Use of thiazide-type diuretics and
ACE inhibitors/ARBs showed an overall upward trend, which
was not statistically significant compared with that predicted
by the time-series model in the 12 months of 2003 following
the publication of the ALLHAT findings (p>.05). The relative
percentage of CCBs diminished over time, but was statistically
significantly higher compared with that predicted in the last 4
months of 2003 (p<.05). The percentage of beta-blockers was
stable overall, although statistically significantly higher
compared with the predicted values in the last 7 months of
2003 (p<0.05). Use of alpha-blockers and other-type
antihypertensive diuretics was steady over time, although
statistically significantly lower compared with the predicted
values in the last 5 and 4 months of 2003, respectively
(p<0.05).
Conclusions: The analysis provides evidence that the wellpublicized ALLHAT findings had a limited impact on the
prescribing patters of antihypertensive drugs in Italy. Further
research is warranted to investigate why physicians appeared
to be unresponsive to the new clinical evidence.
Implications for Policy, Delivery, or Practice: These findings
highlight the need for the RER to devote more attention and
resources to improve physician adherence to ALLHAT
pharmacotherapy recommendation for hypertensive patients.
Effective educational programs targeting inpatient and
outpatient physicians to influence their prescribing behavior
are needed.
Primary Funding Source: Agenzia Sanitaria Regionale,
Regione Emilia Romagna, Italy
●Social Security Income and Elderly Mortality
Cristian Meghea, Ph.D.
Presented By: Cristian Meghea, Ph.D., Senior Researcher,
Research, American College of Radiology, 1891 Preston White
Drive, Reston, VA 20191; Tel: 703-648-8983;
Email: cmeghea@acr.org
Research Objective: The research literature generally finds a
positive relationship between income and health over many
populations and many time periods, but recent studies found
the relationship to weaken at older age. It is critical to
understand the causal relationship between elderly income
and mortality, especially in the light of the dramatic
demographic changes to take place in the near future, and at a
time when reform of the Social Security program is imminent.
It is however difficult to establish causality since income and
health are jointly determined. This study uses a new natural
experiment to address the causal effect of income on the
mortality of retired elderly. I use an exogenous shift in Social
Security benefits for divorced retired women to estimate the
impact of income on their mortality.
Study Design: Data comes from the New Beneficiary Data
System (NBDS), a survey developed by the Social Security
Administration. The first wave was administered in 1982
yielding a sample of 18,599 new beneficiaries represented
about 2 million individuals beginning to receive benefits
during 1980-1981. There was a follow-up interview conducted
in 1991 on the initial respondents. Matched data from the
SSA administrative records complete the NBDS. Under
current law, a divorced spouse can claim Social Security
spousal benefits on her ex-husband’s Social Security record if
their marriage lasted at least ten years. In addition, if an exspouse dies, a woman becomes entitled to widow benefits,
roughly double the amount of spousal benefits. I exploit this
natural experiment using instrumental variable and treatment
effect techniques, in a multiple regression framework, to
investigate the effect of income on the mortality of the elderly.
Population Studied: The US elderly entering retirement.
Principal Findings: I do not find an association between
income and the ten-year mortality across all elderly. To
correctly identify the causal effect of income on mortality, I
restrict the sample to divorced women. Instrumental variable
estimation shows no effect of income on mortality. For a
more precise identification I further restrict the sample to only
divorced women receiving spousal benefits. The treatment
effect analysis comparing the group of divorced women whose
ex-husband is alive to the higher-benefit treatment group of
divorced women whose ex-husband is deceased also finds no
effect of income on the mortality of elderly divorced women.
Conclusions: Much of literature finds that socioeconomic
status is a major determinant of health, but that seems to be
not true late in life. A better socioeconomic status at an early
age may lead to better health outcomes and a longer life, and
that is when policies that enhance socioeconomic status are
the most effective in improving health. However, if the policy
interventions come late in life, the improvement in
socioeconomic status is likely to have no effect on health and
mortality.
Implications for Policy, Delivery, or Practice: The results of
this study provide proof to the policy maker that increases in
income at older ages may not have the expected positive effect
on health. Only policy interventions at earlier ages seem to
lead to better health outcomes and longer lives.
Primary Funding Source: No Funding
●Starting HAART in a Public HIV Care System in
Mozambique: Identifying Priorities for Health Services
Research
Mark Micek, M.D., M.P.H., Kenneth Gimbel-Sherr, M.P.H.,
Sarah Gimbel-Sherr, RN; Eduardo Matediane, M.D., Pablo
Montoya, M.D., M.P.H., Wendy Johnson, M.D., M.P.H.,
Stephen Gloyd, M.D., M.P.H.
Presented By: Mark Micek, M.D., M.P.H., Assistant Clinical
Professor, Health Services, University of Washington, 1107 NE
45th Street, Suite 427, Seattle, WA 98105; Tel: 206-543-8382;
Fax: 206-685-4184; Email: mmicek@u.washington.edu
Research Objective: Weak health systems have been
identified as a major obstacle to achieving goals for expanding
ARV treatment access in developing countries. Analyzing the
flow of patients through HIV care systems can help identify
barriers leading to patient attrition, and to develop targeted
health-services interventions that could lead to improved ARV
access. This study aims to describe the flow of patients
through two public HIV care systems in central Mozambique
which have offered public-sector ARV treatment since June
2004.
Study Design: We analyzed routinely collected data from
public HIV testing (VCT, youth-VCT, and women at pMTCT)
and treatment centers in 2 cities in central Mozambique from
January 2004 through September 2005. Each city contained
multiple testing centers and one primary public HIV treatment
center. We determined the flow of patients through the
following steps: (1) HIV testing; (2) arrival of HIV-positive
people to an HIV treatment center; (3) CD4 testing; and (4)
starting HAART in eligible patients. Drop-off rates and
median lag times between each of the steps were calculated.
The number of additional people starting HAART if drop-offs
were reduced to 0 was estimated individually for each step to
identify priority areas for improvement.
Population Studied: People participating in HIV care in
central Mozambique.
Principal Findings: Significant drop-offs were noted between
each step required to start HAART. Of those testing HIV-
positive at local public HIV testing centers, about 58% arrived
at a public HIV treatment center, at a median of 1 day after
HIV testing. CD4 testing was obtained in 75% of adults
arriving at treatment centers. Of those with initial CD4 counts
<200 at the treatment centers between July 2004 and June
2005, 46% started HAART at a median lag-time of 67 days
after CD4 testing. Based on a model incorporating the above
results, individually eliminating the drop-off of step 4 resulted
in the most additional patients starting HAART per month,
although some differences were observed between cities and
testing sites.
Conclusions: Evaluation of the flow of people through HIV
care systems in developing countries can help identify
problems that limit the number of patients starting HAART.
In our model, starting eligible patients on HAART at HIV
treatment facilities was the major barrier in this process.
Further research is ongoing to better understand the causes of
attrition. Effective health services interventions aimed at
improving counseling, expanding mid-level involvement in
care, and rapidly decentralizing services may help to improve
access to ARV therapy.
Implications for Policy, Delivery, or Practice: Analyzing the
flow of patients through HIV care systems in developing
countries with expanded access to ARV medications is critical
to isolate the main barriers to starting HAART in these
settings. These results can guide policy-makers to develop
targeted health-systems research and strategies to overcome
these obstacles.
Primary Funding Source: PEPFAR, TAP
●Short-lived Influence on Prescribing Trends Following
Publication of the ALLHAT Trial
Steve Morgan, Ph.D., Colette Raymond, PharmD, Ken Basset,
M.D., Ph.D.
Presented By: Steve Morgan, Ph.D., Assistant Professor and
Research Lead (Pharmaceutical Policy), Centre for Health
Services and Policy Research, University of British Columbia,
429-2194 Health Sciences Mall, Vancouver, WA V6T 1Z3; Tel:
(604) 822-7012; Fax: ; Email: morgan@chspr.ubc.ca
Research Objective: The Antihypertensive and Lipid-Lowering
Treatment to Prevent Heart Attack Trial (ALLHAT) that
strongly supported use of thiazide diuretics, is associated with
an immediate change in antihypertensive drugs purchased by
elderly and insured populations. However, it is unknown or if
these changes were specific to patients with relatively
uncomplicated hypertension. It is further unknown whether or
not these immediate changes in prescribing behaviours were
sustained for long-term periods.
Study Design: We studied antihypertensive drug use,
stratified by evidence of comorbidities, by analyzing
administrative data describing medical, hospital, and
pharmaceutical use from 1996 to 2004, inclusive. The
antihypertensive drug (or drugs) purchased on the date that a
resident filled his or her first antihypertensive prescription
defined his or her first-line therapy.
Population Studied: We examined whether the change in
favour of thiazides immediately following the publication of
ALLHAT in December 2002, was sustained for the entire
province of British Columbia (BC), Canada (approximately 4.1
million residents).
Principal Findings: The publication of ALLHAT is associated
with an immediate change in antihypertensive prescribing
patterns. While first-line prescribing of beta-blockers and
calcium-channel blockers continued on a downward trend,
there was an abrupt increase in use of thiazides and a
decrease in the use of ACE-inhibitors as first-line therapies.
However, within one year of the ALLHAT publication, first-line
antihypertensive prescribing for uncomplicated patients began
to revert to pre-ALLHAT trends. Similar, though less dramatic
results were found among the 28% of antihypertensive drug
users with identified comorbidities. The proportion of incident
users that received thiazides increased following ALLHAT
publication, while the proportion that received ACE-inhibitors
decreased. By the end of 2004, the proportion of patients
initiating antihypertensive therapy with an ACE-inhibitor was
near pre-ALLHAT levels while thiazide use continued to
decline.
Conclusions: The prescribing patterns and/or behavior
changes following the publication of ALLHAT were short lived.
The increase in thiazide diuretic use amongst incident
antihypertensive users observed in the first six months of
2003, was lost to ACE-inhibitors in the year that followed.
Thus, while it is encouraging that well-publicized trial results
influence prescribing patterns, long-term trends may reflect
the significant financial interests in hypertension treatment as
much as (or perhaps more than) scientific evidence.
Implications for Policy, Delivery, or Practice: Ongoing
dissemination of clinical trials in which the 'champions' are
older, non-patented medicines, may need to be adopted by
policy-makers and medical associations in order to compete
with promotion by manufacturers of newer more expensive
drugs.
Primary Funding Source: Canadian Institute for Health
Research
●Race & Ethnicity in Health Services Research
Susan Moscou, MSN, M.P.H., Ph.D.(c)
Presented By: Susan Moscou, MSN, M.P.H., Ph.D.(c),
student, Heller School of Social Policy, Brandeis University, 34
Sunnyside Drive, Yonkers, NY 10705; Tel: (914) 966-7184; Fax:
(212) 854-1155; Email: smoscou@earthlink.net
Research Objective: 1) Ascertain how health services
researchers operationalized and conceptualized race and
ethnicity and how they collected and analyzed data using racial
and ethnic variables. 2) Ascertain whether funding agencies
and journal editors contributed to the practice of collecting
data on race and ethnicity.
Study Design: Semi-Structured Interviews (approximately 60
minutes); Researchers: 33; Non-Probabilistic Sampling
Strategies: (a) quota, (b) purposeful, (c) reputational.
Context: Role of funding agencies & journals. Semi-structured
interviews (approximately 30 minutes); 6 Funding Agencies (4
Federal, 2 private) 7 Journal Editors (3 clinical, 4 policy);
Convenience Sampling
Population Studied: 1) Health services researchers-primary
research population 2) Funders--context only 3) Journal
Editors--context only
Principal Findings: The study findings showed that most
respondents routinely collect information on race and
ethnicity. Thirty six percent (36%) of respondents believed that
race was biological, 12% believed ethnicity was biological, and
21% straddled biological and social definitions of race.
Researchers reported using standardized racial and ethnic
classifications to ensure generalizability and comparisons of
their findings. Gaining enough statistical power was obtained
in several ways: (1) study participants selected their racial and
ethnic identity from a pre-determined list, (2) study
participants were asked to select a single racial or ethnic
identity, or (3) researchers imposed a racial or ethnic identity.
The data show that utilizing standard racial and ethnic
categories produced assumptions about research study
participants. In addition, uniform racial and ethnic
classifications implied similar behaviors, characteristics, and
genetics. Racial and ethnic variables often served as proxies
for social factors (marginalization, inequality, and social
injustice) and socioeconomic factors such as poverty and
class. Several respondents studied other variables of interest
(neighborhood characteristics and stature) that they believed
were better at advancing knowledge about health differentials.
Moreover, these variables did not contribute to unwarranted
assumptions about racial and ethnic groups. Funding
agencies had a role in the way that respondents collected
racial and ethnic data. Although journal editors did not
require publishable articles to include racial and ethnic data,
some editors expected articles to contain these data.
Conclusions: 1) Race and ethnicity were proxies for important
social variables of interest. 2) Researchers were straddling
biological and social understandings of race and ethnicity.
3) Multiple meanings of race and ethnicity often were
operating at the same time. 4) Measuring race and ethnicity
necessitated stratification by race and ethnicity. 5) Enforced
use of racial and ethnic categories: (a) excludes study
participants, (b) negates study participants self-reported
identity, (c) maintains power within the research community,
(d) instills a monolithic identity that attributes variation to
culture or genes. 6) Federal funding agencies did contribute
to the practice of collecting racial and ethnic data. 7) Journal
editors did not require racial and ethnic data in articles
considered for publication.
Implications for Policy, Delivery, or Practice: 1) Standard
racial and ethnic categories: (a) do not capture the diversity of
research population, (b) may ignore how a research
participant views self, (c) promotes stereotypes and
misinformation, (d) promulgates the belief that racial & ethnic
differences exist. 2) Routinization of racial and ethnic variables
detracts HSR from developing and using variables to
measure: (a) racism, (b) class, (c) gender bias. 3) Funding
for social problems may be seen as unnecessary because of
the individual focus on racial and ethnic groups rather than a
societal focus on: (a) neighborhood characteristics, (b) class,
(c) racism
Primary Funding Source: No Funding
●Creating a Two-way Intervention dialogue: Practical
Suggestions for Facilitating Quality improvement Within
Healthcare Organizations
Louise E. Parker, Ph.D., JoAnn E. Kirchner, M.D., Laura
Bonner, Ph.D., Jacqueline J. Fickel, Ph.D., Elizabeth M. Yano,
Ph.D., Mona J. Ritchie, M.S.W.
Presented By: Louise E. Parker, Ph.D., HSR&D Center for
Mental Health Outcomes Research and HSR&D Center for
the Study of Healthcare Provider Behavior, VA, 1 Warwick Park,
#1, Cambridge, MA 02140; Tel: (617) 497-4952;
Email: parkerlouise@earthlink.net
Research Objective: There are two primary competing
healthcare quality improvement (QI) methods. Continuous
Quality Improvement is a bottom-up, participatory approach.
Evidence-Based Practice (EBP) is a top-down, expert-led
approach. Participation promotes buy-in and takes local
conditions and needs into account but can be burdensome.
EBP advocates argue that by following expert developed
guidelines, practitioners can provide quality care with minimal
burden. We propose melding the two approaches by creating
a two-way dialogue between implementers and healthcare
facility staff. Providers can then avail themselves of the latest
evidence while maintaining the ability to tailor interventions to
fit local conditions. It is not exactly clear, however, how to
conduct such a dialogue. We examined the ways in which
managers and frontline providers prefer to communicate with
QI implementers. We also examined the types of information
that they reported would be most likely to convince them to
adopt new ways of working. Our goal was to understand both
how implementers can market quality improvement to staff
and how staff, in turn, can convey information about local
circumstances and implementation problems to
implementers.
Study Design: We conducted semi-structured interviews with
frontline providers, frontline administrators, and middle and
upper managers across five VA practices participating in a
depression care QI initiative. Utilizing a grounded theory
approach, we conducted a content analysis during iterative
reviews of the verbatim interview transcripts. To enhance
conceptual development and ensure coding consistency, two
members of the research team coded all the relevant text and
met regularly to resolve differences and refine their coding
scheme and its underlying constructs.
Population Studied: We interviewed 53 frontline providers
and administrators and 19 middle and upper level managers.
Principal Findings: Informants believed that stakeholders
from all organizational levels should participate in QI
implementation, although they expressed concerns about
burden. Frontline staff offered practical suggestions for
maximizing participation while minimizing its costs (e.g.,
utilizing existing meeting structures). Informants indicated
that in-person communication is the most effective, although
managers appeared to be more amenable to written
communication (e.g., email) than were frontline providers.
Neither group expressed a clear preference for either
quantitative or qualitative information, although psychological
research suggests that vivid qualitative information is the
most persuasive. There were some differences between the
types of argument content that managers and providers would
find persuasive. For example, whereas both groups were
interested in quality of care, only managers were interested in
cost information. Both groups indicated that peers would be
convincing information sources; managers indicated that they
would also find experts convincing.
Conclusions: Although concerned about the time that
participation requires, informants believed that it was
important for stakeholders from all organizational levels to be
involved in QI efforts. They offered practical suggestions for
facilitating participation and for transferring information
between QI implementers and healthcare staff.
Implications for Policy, Delivery, or Practice: We believe
that successful QI requires two-way communication between
QI implementers and managerial and frontline staff. We
examined how best to communicate with and involve staff so
as to increase the probability that they will remain engaged in
QI efforts, thereby increasing the probability that those efforts
will succeed.
Primary Funding Source: VA
●Does the Public Believe Marijuana Use is Harmful?
Survey Results and Policy Implications
Kimberly Pukstas, MA, Ph.D. candidate
Presented By: Kimberly Pukstas, MA, Ph.D. candidate, Heller
School for Social Policy and Management, Brandeis
University, 7106 SE 14th Avenue, Portland, OR 97202; Tel: 781864-3375; Email: Pukstas@brandeis.edu
Research Objective: Recent ballot initiatives to decriminalize
marijuana use for either medicinal or recreational purposes
have raised concerns about how the public views the harms of
marijuana use. This study explored the link between public
attitudes towards marijuana use and their support for
marijuana regulations and prevention.
Study Design: Residents from two counties in Massachusetts
were randomly selected from juror lists and then asked to
participate in a cross-sectional survey. Participants were
asked about their support for various marijuana regulation
and prevention activities. In addition, information was
collected on participant demographics, substance use
behavior and their perceptions of the harms and benefits of
marijuana usage. Hierarchical multiple regression modeling
was then used to isolate significant predictors of support.
Population Studied: All participants were English-speaking
adults aged 18 and over. A high majority were registered
voters in Massachusetts. Response rates were favorable
(88.6%) with a sample of 481 participants.
Principal Findings: Results demonstrate an important link
between how an individual views the harmfulness of a drug
and how that individual wants the drug to be regulated. More
than any other factor, the perception of marijuana’s
harmfulness to society explained drug policy preferences.
Contributing to the perception of harm were beliefs that: 1)
marijuana is a gateway drug, 2) marijuana causes a loss of
motivation, 3) marijuana causes health problems, and 4) that
marijuana use increases the chance of a car accident.
Conclusions: Participants supported a wide variety of
approaches to regulating marijuana use. After controlling for
demographics and personal experience with drugs, the
perception of the drug’s harms and benefits were strong
predictors of opinion. Results suggest that public health
information about the harms and benefits of marijuana can
influence both public opinion and public policymaking.
Implications for Policy, Delivery, or Practice: Beyond poll
numbers and demographics, little is known about the voters
who support drug policy changes via ballot initiatives. Yet,
this study suggests that voters’ beliefs and attitudes about
drug use can have a significant impact on their policy
positions. If education and public health efforts are to have
any influence on the public and their policymaking, they
should address perceptions of the risks and benefits of drug
use.
Primary Funding Source: Heller School for Social Policy and
Management
●How Context Affects Beneficaries Experiences with
Medicare Advantage Plans
Cynthia Robins, Ph.D., Amy Heller, Ph.D.
Presented By: Cynthia Robins, Ph.D., Senior Study Director,
Westat, 1650 Research Blvd, Rockville, MD 20850; Tel: (301)
738-3524; Email: cynthiarobins@westat.com
Research Objective: To explore how contextual factors affect
Medicare beneficiaries experiences with their managed care
plans and their CAHPS ratings of their health plan.
Study Design: Qualitative four site ethnographic community
assessment where the sites where chosen based on their
overall adjusted Medicare managed care plan rating, with each
site representing a different quartile of plan ratings. The sites
in this study were :• Thurston County, Washington- the lowest
quartile of the adjusted plan ratings •Cumberland County,
New Jersey • Centre County, Pennsylvania • McLennan
County, Texas the highest quartile of the adjusted plan ratings.
While sites varied, study characteristics that were held
constant were: • Relative homogeneity with respect to local
resources, such as the number of hospital beds per capita,
• Percentage of seniors in the population, •Percentage of
veterans, • Per capita income, • Percentage of families below
poverty. The primary data collection method for this study
involved rapid ethnographic assessment of each of the four
sites.
Population Studied: Medicare beneficiaries enrolled in
Medicare managed care plans in the 4 sites.
Principal Findings: The findings from this study reinforced
the notion that Medicare is not “the same” for beneficiaries
across the country. Rather, any individual’s experience with
this Federal health insurance program varies with a number of
factors. The overall rating of Medicare health plans in the
CAHPS survey is a combination of a plan's benefit and
structure, as well as contextual factors such as: the
relationship of the plan and participating service providers to
the local community, availability of formal and informal
medical services and supports and individual expectations
surrounding the care experience. Additional factors that
appeared to influence interviewees’ perceptions of their
Medicare managed care experiences included: •The
individual’s own health status (i.e., the extent to which s/he
actually needed to use his/her insurance product),
• The medical and ancillary resources that existed in each
community, and the extent to which those medical resources
were actually available to individuals. Cultural norms impact
beneficiaries willingness to access to care and services
outside the immediate 'local' community. Statistical case mix
adjustment made to adjust for individual differences in
CAHPS survey respondents do not fully account for all the
differences in the health plan ratings.
Conclusions: Medicare managed care is not a homogeneous
program and there are distinctive local differences in people's
experiences, expectations and CAHPS ratings of managed care
plans.
Implications for Policy, Delivery, or Practice: Survey data
collected at a local level may reveal local and regional
differences when aggregated at a state or national level for
which statistical methods may not be able to fully explain the
geographical differences. Ethnographic and other qualitative
methods might be needed to help explain the differences in
thoughts and attitudes when respondents complete survey
questionnaires.
Primary Funding Source: CMS
●Knowledge Transfer: Creating Policy for Quality Northern
Rural Health Workplaces
Ellen Rukholm, BScN, MScN, Ph.D., Pat Bailey, Ph.D., Deb
Bakker, Ph.D., Manon Lamonde, Ph.D., Raymond Pong, Ph.D.,
Syra Porter, MA
Presented By: Ellen Rukholm, BScN, MScN, Ph.D., Professor,
Nursing, Laurentian University, 935 Ramsey Lake Road,
Sudbury, Ontario, P3E 2C6; Tel: 705-522-4074; Fax: 705-5221733; Email: erukholm@laurentian.ca
Research Objective: The primary objective was to study how
findings from recent research reports about quality health care
workplace environments have been disseminated and
implemented in Northeastern Ontario acute and long term
care facilities including facilities in small rural communities
with high francophone and aboriginal populations. The
secondary objective was to determine how health care human
resource policy recommendations can be formulated by and
for local, regional, provincial and national jurisdictions.
Study Design: This study utilized a participatory action
research design involving mixed methods in four stages.
Stage I gathered perceptions, with a cross-sectional survey,
from decision-makers and health care professionals regarding
the dissemination and utilization of workplace
recommendations published in government and professional
reports. Stages II and III involved holding focus groups first
with health care professionals and then with chief executive
officers (CEOs). These focus groups collected data about
barriers and enablers to implement workplace policy
recommendations within different health care agencies.
Results of the previous focus group were shared with the
participants of subsequent focus groups at each stage in the
project. Stage IV involved the formation of working groups
comprised of health care professionals, CEOs and
government policy makers. In this stage, quality workplace
priorities were identified to develop policy recommendations.
Population Studied: Surveys were sent to 180 acute and long
term care facilities in Northeastern Ontario. Focus group
participants included decision makers and health care
professionals at the senior management levels as well as
government policy representatives and national nursing
leaders.
Principal Findings: Survey results indicated that sixty percent
of the agencies contacted for this study were in rural areas.
The majority of both CEOs (54%) and health care
professionals (81%) had no knowledge of the reports. CEOs
were predominantly from long term care institutions (56%).
Whereas, there was an almost even split between acute (44%)
and long term care facilities (45%) for health care
professionals. The most common form of institutional
dissemination of health reports by CEOs was formal
circulation (52%). The major barrier to implementation
identified by both CEOs and health care professionals in focus
groups was a lack of resources (time, money, human
resources). The top three priorities to facilitate knowledge
transfer about quality workplaces were: 1) resources, 2)
communication, and 3) accountability for leaders. Policies
should address: the inclusion of quality workplace indicators
in accreditation standards, leadership valuing and knowledge
of quality workplace environments, evaluation of workplace
environments, linkage with the equivalent of local government
health authorities, applicability to specific regional needs or
concerns including issues of geographic isolation.
Conclusions: Our study has found that in this Northeastern
region of Canada, there is limited knowledge transfer or
uptake of quality workplace research reports. It is suggested
that the creation of a knowledge network with face-to-face and
telecommunicated dialogue may facilitate knowledge uptake.
Implications for Policy, Delivery, or Practice: Results of this
study will assist Health Canada to promote and facilitate the
development of workplace quality assurance policies with
health care agencies in northern and rural contexts. Findings
of the study may be utilized by health care agencies in similar
local, regional, and national jurisdictions.
Primary Funding Source: Health Canada
●Application of Cost-Benefit Analysis in Medicaid
Mihail Samnaliev, Ph.D.
Presented By: Mihail Samnaliev, Ph.D., Research Associate,
Center for Health Policy and Research, University of
Massachusetts Medical School, 222 Maple Av, Shrewsbury,
MA 01545; Tel: (508)856-1765;
Email: Mihail.Samnaliev@umassmed.edu
Research Objective: There have been numerous
philosophical, moral and empirical challenges surrounding the
use of cost-benefit analysis (CBA) in public health care
resource allocation and decision making. Some of these
include concerns about equality in access to health care,
rejection of the consequentialist approach that underpins
CBA, objection to the CBA test where benefits must
overweight costs, and practical difficulties of identifying and
quantifying appropriate costs and especially benefits.
However, limited Medicaid budgets have effectively resulted in
health care rationing through a combination of strict eligibility
requirements and types of benefits reimbursable by Medicaid.
The objective of this article is to study the extent to which
state Medicaid programs have incorporated CBA in the
evaluation of existing or new policies and the extent to which
this method has been used to inform or as an alternative to
cost-containment policies.
Study Design: Review of published and unpublished articles,
reports and other documents involving economic evaluation
or cost containment efforts of Medicaid programs and
policies. The focus is on CBA with some reference to costeffectiveness analysis.
Population Studied: Medicaid beneficiaries
Principal Findings: Cost-Benefit Analysis has been underused
but still pursued by state Medicaid programs. Some examples
include evaluations of the Medicaid Ticket to Work Act,
studies of co-payment elasticity of demand, and studies of
costs and effects of certain medications covered by Medicaid.
CBA has not been used systematically; the literature is
inconsistent in the way cost, benefits and effects are identified
and estimated with the focus most often falling on cost
containment. There is a lack of clear distinction between state,
federal, social and private perspective with state Medicaid
rather than social costs, usually being of primary concern.
Conclusions: Incorporating a CBA perspective has yielded
important input in the evaluation of Medicaid policies and
programs and will likely continue to be used, at least
informally. However, lack of full understanding of the
principles of CBA as well as lack of ability to collect data on
health effects/outcomes has likely limited use of this method
by Medicaid programs.
Implications for Policy, Delivery, or Practice: Models for
translating health economic research into practice may be
more effective if they target policy makers directly involved in
Medicaid decision making. This could be attempted through a
brief, non-technical exposition of the principles of economic
evaluations in the form of a handbook aimed at Medicaid
decision-makers. Such approach could increase awareness of
the value of an economic perspective and enhance
collaborations between decision makers and economists that
would positively impact discussions, design and evaluations
of Medicaid policies. It could create incentives for collection of
more detailed data on health outcomes that would improve
measurements of benefits or costs.
Primary Funding Source: No Funding
●Barriers to Following Guideline Recommendations for
Antipsychotic Medication Management
Jeffrey Smith, Ph.D. Candidate, Richard R. Owen, MD,
Geoffrey M. Curran, Ph.D.
Presented By: Jeffrey Smith, Ph.D. Candidate,
Implementation Research Coordinator, VA Mental Health
Quality Enhancement Research Initiative, Central Arkansas
Veterans Healthcare System, 2200 Fort Roots Drive, Building
58 (152/NLR), North Little Rock, AR 72114; Tel: (501)257-1066;
Fax: (501)257-1707; Email: Jeffrey.Smith6@med.va.gov
Research Objective: Antipsychotic medication is the most
widely utilized treatment for schizophrenia in VA settings, and
VA has established guidelines for the appropriate use of these
medications. This abstract reports results from a formative
evaluation assessing barriers to following guideline
recommendations for antipsychotic medication management
in a multi-site project, ‘A Study of Strategies to Improve
Schizophrenia Treatment’ (ASSIST), to develop and test multicomponent interventions to improve care for patients with
schizophrenia.
Study Design: Semi-structured qualitative interviews were
conducted during site visits with key informant mental health
administrators and clinical staff at ten participating VA
medical centers. Interviews assessed barriers to following
guideline recommendations regarding: (1) use of moderate
antipsychotic doses, (2) monitoring for potentially serious
metabolic side effects of newer antipsychotic medications, and
(3) use of clozapine for treatment-refractory patients.
Interview notes recorded by primary and secondary
interviewers were analyzed and coded using qualitative data
analysis methods to identify common barriers and themes
related to following guideline recommendations.
Population Studied: 10 VA mental health administrators and
49 mental health clinical staff
Principal Findings: Systems-level barriers included: (a) lack of
mechanisms, structural resources or staff to ensure
antipsychotic side effect monitoring is completed; (b)
perceived limitations of an existing computerized clinical
reminder for side effect monitoring; (c) lack of training on use
of the clinical reminder; (d) difficulty interpreting and
complying with VA policy on clozapine use; and (e) poor
coordination with pharmacy. Provider-level barriers included:
(a) lack of awareness of guideline recommendations; (b) low
perceived need for quality improvement; and (c) general
clinician resistance to change. Patient-level barriers included:
(a) differential response to and toleration of high antipsychotic
doses; and (b) patient compliance issues related to side effect
monitoring.
Conclusions: A range of barriers at multiple levels work
individually and collectively to limit adherence to guideline
recommendations for antipsychotic medication management.
Feedback on barriers from site participants has been
incorporated into the development of a collection of
intervention tools and strategies that are being tested for their
effectiveness in improving care for schizophrenia.
Implications for Policy, Delivery, or Practice: Efforts to
improve clinical care may be more successful if specific
barriers to following guideline recommendations are elicited
from stakeholders and addressed in the development of
remedial intervention tools/strategies. Incorporating clinical
stakeholder feedback into intervention design may also make
intervention tools/strategies more relevant to routine clinical
practice.
Primary Funding Source: VA
●A Pilot Study of Guided Care: Cost and Utilization
Outcomes
Martha Sylvia, RN, MSN, MBA, Michael Griswold, Ph.D.,
Linda Dunbar, Ph.D., Margaret Park, M.P.H., Charles Boult,
MD, M.P.H., MBA
Presented By: Martha Sylvia, RN, MSN, MBA, Clinical
Outcomes and Research Manager, Care Management, Johns
Hopkins HealthCare, 6704 Curtis Court, Glen Burnie, MD
21060; Tel: 410-762-5267; Fax: 410-424-4606;
Email: msylvia@jhhc.com
Research Objective: Guided Care is a model of practice that
translates research findings and information technology into a
new approach to caring for older community-dwelling adults
with complex health conditions. In Guided Care, a speciallytrained RN works with 2-4 primary care physicians to provide:
geriatric assessment, evidence-based proactive primary care,
education and coaching for self-management, care
coordination, education and support of caregivers, and access
to community services. The purpose of this pilot study was to
compare the cost and utilization of health care by multimorbid, community-dwelling, older persons receiving Guided
Care (GC) and by those receiving Usual Care (UC).
Study Design: We conducted a prospective, 6-month, quasiexperimental study. We used the Adjusted Clinical Groups
Predictive Model (ACG-PM) to identify older patients at a
primary care practice who were at risk for generating high
insurance expenditures in the coming year. We assigned a
Guided Care nurse to work with the high-risk patients of two
general internists in the practice; the high-risk older patients of
two other general internists in the same practice served as
controls. Data from insurance claims were used to
characterize the Guided Care (GC) and Usual Care (UC)
groups’ demographics, chronic conditions, use of health
services, and generation of insurance expenditures.
Regression plateau models were used to compare the GC and
UC groups’ utilization and costs – and to describe differences
in utilization and costs across a range of risk levels.
Population Studied: High-risk, older, community-dwelling
HMO enrollees who were receiving primary care from one of
four general internists at an urban community primary care
practice in Baltimore.
Principal Findings: At baseline, GC patients were similar to
UC patients in age and gender, but were at higher risk (mean
ACG-PM risk score = 0.34 vs. 0.20, p<0.05). Compared to UC
patients, GC patients had a similar aggregate burden of
chronic disease and similar prevalences of nine specific
chronic conditions. During the six months of follow-up, GC
patients had fewer hospital admissions (0.24 vs. 0.43 per
person), fewer hospital days (0.82 vs. 2.5 per person), and
fewer ED visits (0.15 vs. 0.31 per person) – and they generated
lower total insurance expenditures (mean = $4,586 vs.
$5,964). The regression plateau model suggested a trend
toward larger cost differences among patients with lower ACGPM risk scores (ACG-PM of 0.10: cost difference = $4,340; 0.7:
cost difference = $1,307).
Conclusions: These results suggest that, in the setting of
community primary care, Guided Care may reduce insurance
expenditures for high-risk older adults. Larger controlled trials
are needed to confirm or refute these findings – and to
measure the effects of Guided Care on other outcomes.
Implications for Policy, Delivery, or Practice: In the
Medicare population, 20% of the beneficiaries have 5+ chronic
illnesses and account for 80% of total expenditures. By
improving the quality of care for this vulnerable population,
Guided Care may have the potential to help to control
Medicare’s rapidly rising health care expenditures.
Primary Funding Source: No Funding
●Arkansas’s Response to the Obesity Epidemic: A
Framework for Translating Research into Policy and
Practice
Joseph Thompson, MD, M.P.H., Kevin Ryan, JD, MA, Jennifer
L. Shaw, M.P.H., MAP, Paula Card-Higginson, BS, Michelle B.
Justus, MS, Suzanne McCarthy, M.P.H., MS
Presented By: Joseph Thompson, MD, M.P.H., Arkansas
Surgeon General, Arkansas Department of Health and Human
Services, 1401 West Capitol, Suite 300, little rock, arkansas, AR
72201; Tel: (501) 526-2244; Fax: (501) 526-2252; Email:
thompsonjosephw@uams.edu
Research Objective: Responding to the alarming epidemic of
childhood obesity, states and communities have begun to take
action. In 2003, Arkansas passed multifaceted legislation (Act
1220) to combat childhood obesity. Now in the third year of
implementation, activities both mandated directly by Act 1220
and actions indirectly generated by enhanced awareness have
been implemented. We examined and documented the
development, implementation, and efficacy of these specific
activities in order to determine the components of a
framework that optimally facilitates translation of existing
obesity research and “best practices” into accepted policy and
actions in other settings.
Study Design: Among Act 1220’s requirements are removal of
vending machines from elementary schools, disclosure by
school districts of “pouring contracts” with food/beverage
companies, annual assessment/reporting of individual public
school student’s body mass index (BMI) to parents, creation
of a statewide Child Health Advisory Committee (CHAC), and
formation of local nutrition and physical activity advisory
committees. We reviewed and compared national
recommendations for combating childhood and adolescent
obesity with Act 1220 activities, and identified a framework for
use by others addressing this critical issue.
Population Studied: The population affected includes public
school students and parents, school and school district
personnel, healthcare professionals, policy makers, and
executive and legislative leadership.
Principal Findings: The set of activities directly required
through, and indirectly stimulated by, Act 1220 continue to
evolve and expand. The result is a broad-based multifaceted
set of initiatives involving the health, education, and policymaking communities. A framework emerges that builds upon
national recommendations for action by examining Arkansas’s
singular experience with obesity interventions and activities
undertaken in public schools, legislative, executive, and policy
environments. This framework, which may inform obesity
policy development and implementation efforts elsewhere,
includes four key components: initial assessment, population
interventions, individual interventions, and ongoing
surveillance. Specific activities under some components were
required by the original legislation (e.g., assessing and
reporting BMIs and disclosure of pouring contracts). Other
actions were generated by CHAC recommendations (e.g.,
vending machine restrictions in secondary schools and
development of physical activity requirements for public
school students in grades K–12) or healthcare organizations’
investments (e.g., continuing medical education for pediatric
overweight). Finally, opportunities to build upon and
supplement components in the legislation have been
identified, operationalized, and are contributing to the local
and state response (e.g., ongoing surveillance through a
longitudinal, multi-year BMI database).
Conclusions: In the face of an emerging epidemic, many
national recommendations fail to offer a readily translatable
platform to build support, mobilize resources, and ultimately
effect a positive outcome. As with any effort to confront a new
epidemic, existing knowledge is usually not sufficient to guide
the response and the pace of traditional research is not always
rapid enough to inform policy development. In spite of these
challenges, existing knowledge and rational response must be
formed into accepted policy and implemented actions.
Implications for Policy, Delivery, or Practice: This
translational aspect of informed policy development offers an
opportunity to understand, inform, and improve linkages
between scientific development and practical applications.
Primary Funding Source: RWJF
●Evaluating Facilitation Activities in a VA QUERI
Implementation Project
Carolyn Wallace, Ph.D.
Presented By: Carolyn Wallace, Ph.D., Research Health
Science Specialist, Health Services Research & Development,
Department of Veterans Affairs, 1660 S Columbian Way MS
152, Seattle, WA 98108; Tel: (206)277-6048; Fax: (206)7642935; Email: Carolyn.Wallace1@va.gov
Research Objective: The implementation project had two
goals: 1) increase vaccination rates for influenza and
pneumococcal pneumonia in veterans with a spinal cord
injury or disorder (SCI&D); and 2) assure that 4 evidencebased interventions were adopted at Department of Veterans
Affairs (VA) Spinal Cord Injury (SCI) Centers. This paper
addresses interventions selected to increase vaccination rates
for influenza and pneumococcal pneumonia. Status of each
intervention was assessed during and following completion of
the implementation project. Facilitation, the method to help
clinical and administrative staff in VA SCI Centers adopt the
interventions, was defined as helping individuals and teams to
understand what they need to change and how they need to
change it in order to apply evidence to practice, RycroftMalone et al. 2002.
Study Design: The research component of the
implementation project was a 2-year observational study, with
follow-up 1 and 2 years after project completion. Data about
interventions were collected via semi-structured and openended questionnaires and telephone interviews, notes from
conference calls and e-mail messages. Topics included: status
of each intervention at SCI Centers; problems with
interventions; VA or local systems issues affecting
interventions; characteristics of SCI Centers; and descriptions
of specific situations. Qualitative data were analyzed to
identify patterns and themes within and among topics and to
describe strengths and weaknesses of facilitation activities.
Population Studied: Clinical and administrative staff in VA
SCI Centers and information technology (IT) staff in VA
medical centers with an SCI Center provided data about the
interventions. Respondents were selected because of their
knowledge about an intervention or because they identified
themselves as having interests and/or experience with an
intervention.
Principal Findings: Facilitation was effective for providing
specific information to SCI Center staff about how to carry out
an intervention. However, facilitation did not guarantee either
the adoption or maintenance of an intervention. While having
an intervention available was necessary, it was not sufficient
for an intervention to be adopted and then used. The process
of adopting an intervention was complex and varied at each
SCI Center. Use of facilitation by the project team provided a
means to respond to issues identified by SCI Center staff.
Data collection and discussion about the status of
interventions also led to identification of problems. Facilitation
allowed problem-solving to involve staff from SCI Centers,
members of the project team and VA experts as well as to
affect administrative and clinical systems.
Conclusions: An external facilitator provided advice about
national and general issues and offered suggestions about
local issues, while not intervening in the management of an
SCI Center. An external facilitator gathered information from
different parts of the organization and developed a broad view
of problems and issues. However, because an external
facilitator will lack familiarity with local personnel and
processes, there can be no substitute for local leadership.
Implications for Policy, Delivery, or Practice:
Understanding local processes, structures and decisions
remains important for research and quality improvement
activities. The context in which health care is delivered affects
patients, practitioners and other health care staff.
Primary Funding Source: VA
●An Expert Panel Approach to Developing a Curriculum
for Implementation Science
Margaret Wang, Ph.D., M.P.H., Brian S. Mittman, Ph.D., Lisa
V. Rubenstein, M.D., M.S.P.H.
Presented By: Margaret Wang, Ph.D., M.P.H., Post-doctoral
Research Fellow, RAND/UCLA, 1776 Main St., Santa Monica,
CA 90401; Tel: 310-393-0411, x6077;
Email: margaret_wang@rand.org
Research Objective: The field of healthcare implementation
science, the study of theories and methods to translate
research into practice, is continuing to develop and evolve as
a distinct field of research. A central component of a scientific
field is a formal curriculum for education and training,
specifying the domains of knowledge, skill and experience
required to succeed as a productive researcher. We developed
an expert rating approach to identify and prioritize topics for
inclusion in a formal curriculum for fellowship training
programs, doctoral programs and career development
programs for this emerging field.
Study Design: The curriculum development approach
included distinct components to (1) identify relevant domains,
(2) rate their importance, and (3) assess the training needs of
a diverse sample of students, fellows and researchers. Key
methods in the approach included literature review to compile
preliminary lists of domains; group discussions to clarify,
refine, categorize and expand the domain list; and a formal
rating procedure in which researchers with a range of
experience levels rate each domain on dimensions of
importance, distinctiveness and need.
Population Studied: Contributors and raters included
doctoral students, post-graduate fellows, and junior and
senior researchers from a wide range of disciplines within the
local health services research (implementation science
subfield) community.
Principal Findings: Implementation science draws upon
theories, concepts, research approaches and methods from a
broad range of disciplines within the health sciences, the
social and behavioral sciences and other areas of knowledge.
The list of domains generated by the participants covered a
broad spectrum of these areas, and included numerous
domains common to other areas of health-related research
(i.e., clinical, health services and health policy research), and a
smaller list of domains highly specific to implementation
science. The list of domains included traditional topics such
as theory, research methods and empirical literature, and
several non-traditional domains such as practical skills and
experiences in communication, management, leadership, and
policy making. A comprehensive training program for
implementation research must include internship or other
experiential components to develop the breadth of skills and
experiences needed to succeed in this field.
Conclusions: The modest progress of the development of
implementation science as a field may be traced, in part, to
insufficient preparation and training of researchers active in
the field. Identification of the core domains and skills within
the field will facilitate recognition of, and initiatives to address,
training needs and gaps. The approach we developed to
identify these domains and prioritize topics for a
comprehensive curriculum offers a basis for developing
targeted training programs for scholars and researchers in this
emerging field.
Implications for Policy, Delivery, or Practice: This project
contributes to recognition of the need for enhanced training in
implementation science, and guidance in designing and
delivering this training. Academic leaders, fellowship program
directors and research center leaders should find the results of
this effort useful in enhancing existing programs to train
implementation scientists. Healthcare quality improvement
(QI) stakeholders should benefit from the involvement of a
better-trained research workforce in collaborative efforts to
understand and address healthcare QI challenges and quality
problems.
Primary Funding Source: No Funding
●A National Resource for Survey Research and
Recruitment in Multi-site Studies
Cheryl Wiese, MA, Jessica Ridpath, MA, Denise Boudreau,
Ph.D., Karin Johnson, Ph.D.
Presented By: Cheryl Wiese, MA, Survey Research Program
Manager, Survey Research Program, Group Health Center for
Health Studies, 1730 Minor Ave, Suite 1600, Seattle, WA
98101-1448; Tel: 206-287-2900; Fax: 206-287-2871;
Email: wiese.c@ghc.org
Research Objective: The HMO Research Network (HMORN)
aims to be recognized as the Nation’s premier resource for
population-based health and health care research. The
HMORN is a consortium of 14 health plans situated across all
regions of the US, including six Kaiser Permanente (KP)
Regions. All of the HMORN members have strong research
capabilities, and a commitment to using their collective
scientific capabilities to integrate research and practice for the
improvement of health and health care. The goal of this
presentation is to highlight recent innovations in improving
the quality of survey research and recruitment in multi-site
studies.
Study Design: Interviews with investigators who lead survey
research and recruitment research at HMORN member sites
were conducted in 2005 to assess research capacity, prior
survey research experience and special considerations related
to member populations. This information, combined with the
help and cooperation of the survey and recruitment
investigators across the sites, was used to produce a website
outlining best practices for conducting multi-site survey
research and recruitment. In addition, an independent effort
at the Group Health Cooperative focuses on producing
subject recruitment and advance materials at a literacy level of
6th to 8th grade to ensure research subjects have a clear
understanding of studies to make an informed decision about
whether to participate. Finally, the Group Health Center for
Health Studies Survey Research Program is showcased as an
example of research capacity within the HMORN.
Population Studied: The HMORN member organizations are
the primary research subjects. A number of recruitment and
survey research examples from various member organizations
or sites will be shared.
Principal Findings: The Web-Based guide to Best Practices
for Recruitment and Survey Research is live and available to
HMORN members and could be demonstrated with
screenshots or a live website demonstration. A Readability
Packet is being produced to guide the preparation of written
materials for research subjects at a target literacy level, and an
in-house resource person is available for consulting services.
The Group Health Survey Research Program is a full-service
recruitment and survey research organization with experience
conducting multi-site research across the HMORN.
Conclusions: Great strides have been made in the past year
to facilitate and enhance collaboration among these HMOs
across the nation to conduct research among sample
populations that closely reflect the general population.
Implications for Policy, Delivery, or Practice: This
opportunity to showcase the high quality recruitment and
survey research through the HMORN will provide health
researchers with another avenue for finding appropriate
subjects to advance public health through as efficient means
as possible. The HMO Research Network is a research
resource for its members and for national collaborators.
Primary Funding Source: This project has been funded in
part with Federal funds from the National Institutes of Health,
under Contract No. HHSN268200425212C,