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1.  Peer navigation in African American breast cancer survivors 
Purpose
The purpose of this study was to explore the feasibility and acceptability of a peer navigation survivorship program for African American (AA) breast cancer survivors (BCS) and its potential effects on selected short-term outcomes according to the Quality of Life Model Applied to Cancer Survivors.
Methods
An AA BCS who completed treatment over 1 year prior to the study was trained as a peer navigator (PN), and then paired with AA women completing primary breast cancer treatment (n=4) for 2 months. This mixed-methods, proof of concept study utilized a convergent parallel approach to explore feasibility and investigate whether changes in scores are favorable using interviews and self-administered questionnaires.
Results
Results indicate that the PN intervention was acceptable by both PN and BCS, and was feasible in outcomes of recruitment, cost, and time requirements. Improvements in symptom distress, perceived support from God, and preparedness for recovery outcomes were observed over time. Qualitative analysis revealed six themes emerging from BCS interviews: “learning to ask the right questions”, “start living life again”, “shifting my perspective”, “wanting to give back”, “home visits are powerful”, and “we both have a journey”: support from someone who has been there.
Conclusion
Results support current literature indicating that AA women who have survived breast cancer can be an important source of support, knowledge, and motivation for those completing breast cancer treatment. Areas for future research include standardization of training and larger randomized trials of PN intervention.
Implications for cancer survivors
The transition from breast cancer patient to survivor is a period when there can be a loss of safety net concurrent with persistent support needs. AA cancer survivors can benefit from culturally tailored support and services after treatment for breast cancer. With further testing, this PN intervention may aid in decreasing general symptom distress and increase readiness for recovery post-treatment.
doi:10.2147/PROM.S69744
PMCID: PMC4230185  PMID: 25404863
peer support; African American; breast cancer; survivor
2.  Organizational Attributes and Screening and Brief Intervention in Primary Care 
Addictive behaviors  2013;38(11):2639-2642.
Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening, brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that participated in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of implementation of SBI and treatment.
doi:10.1016/j.addbeh.2013.05.016
PMCID: PMC3759591  PMID: 23899425
alcohol screening; high-risk drinkers; primary care; organizational attributes
3.  Colorectal Cancer Screening in Primary Care: Translating Research into Practice 
Medical care  2010;48(10):900-906.
Background:
Colorectal cancer (CRC) screening is recommended for all adults 50-75 years old, yet only slightly more than one-half of eligible people are current with screening. Since CRC screening is usually initiated upon recommendations of primary care physicians, interventions in these settings are needed to improve screening.
Objectives:
To assess the impact of a quality improvement (QI) intervention combining electronic medical record (EMR) based audit and feedback, practice site visits for academic detailing and participatory planning, and “best-practice” dissemination on CRC screening in primary care practice.
Research Design:
Two year group-randomized trial.
Subjects:
Physicians, mid-level providers and clinical staff members in 32 primary care practices in 19 States caring for 68,150 patients 50 years of age or older.
Measures:
Proportion of active patients up to date (UTD) with CRC screening (colonoscopy within 10 years, sigmoidoscopy within 5 years, or at home fecal occult blood testing within 1 year) and having screening recommended within past year among those not UTD.
Results:
Patients 50-75 years in intervention practices exhibited significantly greater improvement (from 60.7% to 71.2%) in being UTD with CRC screening than patients in control practices (from 57.7% to 62.8%), the adjusted difference being 4.9% (95% CI: 3.8% to 6.1%). Recommendations for screening also increased more in intervention practices with the adjusted difference being 7.9% (95%CI: 6.3% to 9.5%). There was wide inter-practice variation in CRC screening throughout the intervention.
Conclusions:
A multi-component QI intervention in practices that use EMR can improve colorectal cancer screening.
doi:10.1097/MLR.0b013e3181ec5591
PMCID: PMC4107393  PMID: 20808257
Colorectal Cancer Screening; EMR; Quality Improvement
4.  Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study 
ABSTRACT
BACKGROUND
Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).
OBJECTIVE
To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.
DESIGN
A two-phase, 27-month demonstration project.
SETTING
Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).
PARTICIPANTS
Thirty-nine providers were included in the project.
INTERVENTION
A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.
MAIN OUTCOME MEASURES
1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.
KEY RESULTS
The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57 % [95 % CI, −5.35 %, 8.49 %] in adults and −1.89 % [95 % CI, −9.03 %, 5.26 %] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, −16.30 %, [95 % CI, −24.81 %, −7.79 %] in adults and −16.30 [95%CI, −23.29 %, −9.31 %] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.
CONCLUSIONS
This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.
doi:10.1007/s11606-012-2267-2
PMCID: PMC3663943  PMID: 23117955
acute respiratory infections; antibiotic prescribing; electronic health records; clinical decision support
5.  Colorectal Cancer Screening in Primary Care: Theoretical Model to Improve Prevalance in the Practice Partner Research Network 
Health promotion practice  2009;12(2):229-234.
Colorectal cancer (CRC) is the second leading cause of cancer death in the United States (US). Half of Americans above age 50 are not current with recommended screening; research is needed to assess the impact of interventions designed to increase receipt of CRC screening. The Colorectal Cancer Screening in Primary Care (C-TRIP) study is a theoretically-informed group randomized trial within 32 primary care practices. Baseline median proportion of active patients aged 50 years or older up-to-date with CRC screening among the 32 practices was 50.8% (N=55,746). Men were more likely to be screened than women (52.9% vs. 49.2% respectively). Patients 50–59 years of age were less likely to be up-to-date with screening (45.4%) than those in the 60–69 year and 70–79 years groups (58.5% in both groups). Opportunities exist to increase the proportion of CRC screening received in adults age 50 and older. C-TRIP evaluates the effectiveness of a model for improvement for increasing this proportion.
doi:10.1177/1524839909332139
PMCID: PMC2889237  PMID: 19297657
6.  An Application of a Modified Constrained Randomization Process to a Practice-Based Cluster Randomized Trial to Improve Colorectal Cancer Screening 
Contemporary clinical trials  2008;30(2):129-132.
Background
When designing cluster randomized trials, it is important for researchers to be familiar with strategies to achieve valid study designs given limited resources. Constrained randomization is a technique to help ensure balance on pre-specified baseline covariates.
Methods
The goal was to develop a randomization scheme that balanced 16 intervention and 16 control practices with respect to 7 factors that may influence improvement in study outcomes during a 4-year cluster randomized trial to improve colorectal cancer screening within a primary care practice-based research network. We used a novel approach that included simulating 30,000 randomization schemes, removing duplicates, identifying which schemes were sufficiently balanced, and randomly selecting one scheme for use in the trial. For a given factor, balance was considered achieved when the frequency of each factor’s sub-classifications differed by no more than 1 between intervention and control groups. The population being studied includes approximately 32 primary care practices located in 19 states within the U.S. that care for approximately 56,000 patients at least 50 years old.
Results
Of 29,782 unique simulated randomization schemes, 116 were determined to be balanced according to pre-specified criteria for all 7 baseline covariates. The final randomization scheme was randomly selected from these 116 acceptable schemes.
Conclusions
Using this technique, we were successfully able to find a randomization scheme that allocated 32 primary care practices into intervention and control groups in a way that preserved balance across 7 baseline covariates. This process may be a useful tool for ensuring covariate balance within moderately large cluster randomized trials.
doi:10.1016/j.cct.2008.10.002
PMCID: PMC2680348  PMID: 18977314
Randomization techniques; cluster randomized trials; covariate balance; study design; practice based research networks; colorectal cancer screening
7.  High Performance in Screening for Colorectal Cancer: A Practice Partner Research Network (PPRNet) Case Study 
Introduction
Colorectal cancer (CRC) screening is recommended for average risk adults age 50 and older, yet half of eligible US adults are not current. Competing demands within primary care suggest a systematic process is needed for improvement. This case study of highest performing practices within the Colorectal Screening in Primary Care study (C-TRIP) explains practice strategies used and provides a model for improving CRC screening in primary care.
Methods
A case study design was used to analyze practice performance data and qualitative data obtained from site visits, network meetings and correspondence. The Practice Partner Research Network (PPRNet) Translating Research into Practice (TRIP) Quality Improvement (QI) model provided an analytic framework to evaluate five highest performing practices in the C-TRIP intervention. Practice strategies were grouped within the concepts: prioritize performance (PP), redesign delivery system (RDS), electronic medical record tools (EMR), and activate the patient (AP).
Results
Thirteen specific practice strategies were exemplified within these four concepts (PP, RDS, EMR, AP). Most or all of these strategies were used by the practices that achieved a rate of up to 78% of adults screened for CRC.
Conclusions
Primary care practices achieving a high proportion of CRC screening use systematic processes in the organization of their care. This case study provides a framework to organize systems that increase early detection and prevention of colorectal cancer.
doi:10.3122/jabfm.2009.02.080108
PMCID: PMC2696281  PMID: 19264937
colorectal cancer screening; primary care; quality improvement; practice-based research
8.  Implementing change in primary care practices using electronic medical records: a conceptual framework 
Background
Implementing change in primary care is difficult, and little practical guidance is available to assist small primary care practices. Methods to structure care and develop new roles are often needed to implement an evidence-based practice that improves care. This study explored the process of change used to implement clinical guidelines for primary and secondary prevention of cardiovascular disease in primary care practices that used a common electronic medical record (EMR).
Methods
Multiple conceptual frameworks informed the design of this study designed to explain the complex phenomena of implementing change in primary care practice. Qualitative methods were used to examine the processes of change that practice members used to implement the guidelines. Purposive sampling in eight primary care practices within the Practice Partner Research Network-Translating Researching into Practice (PPRNet-TRIP II) clinical trial yielded 28 staff members and clinicians who were interviewed regarding how change in practice occurred while implementing clinical guidelines for primary and secondary prevention of cardiovascular disease and strokes.
Results
A conceptual framework for implementing clinical guidelines into primary care practice was developed through this research. Seven concepts and their relationships were modelled within this framework: leaders setting a vision with clear goals for staff to embrace; involving the team to enable the goals and vision for the practice to be achieved; enhancing communication systems to reinforce goals for patient care; developing the team to enable the staff to contribute toward practice improvement; taking small steps, encouraging practices' tests of small changes in practice; assimilating the electronic medical record to maximize clinical effectiveness, enhancing practices' use of the electronic tool they have invested in for patient care improvement; and providing feedback within a culture of improvement, leading to an iterative cycle of goal setting by leaders.
Conclusion
This conceptual framework provides a mental model which can serve as a guide for practice leaders implementing clinical guidelines in primary care practice using electronic medical records. Using the concepts as implementation and evaluation criteria, program developers and teams can stimulate improvements in their practice settings. Investing in collaborative team development of clinicians and staff may enable the practice environment to be more adaptive to change and improvement.
doi:10.1186/1748-5908-3-3
PMCID: PMC2254645  PMID: 18199330
9.  Using a summary measure for multiple quality indicators in primary care: the Summary QUality InDex (SQUID) 
Background
Assessing the quality of primary care is becoming a priority in national healthcare agendas. Audit and feedback on healthcare quality performance indicators can help improve the quality of care provided. In some instances, fewer numbers of more comprehensive indicators may be preferable. This paper describes the use of the Summary Quality Index (SQUID) in tracking quality of care among patients and primary care practices that use an electronic medical record (EMR). All practices are part of the Practice Partner Research Network, representing over 100 ambulatory care practices throughout the United States.
Methods
The SQUID is comprised of 36 process and outcome measures, all of which are obtained from the EMR. This paper describes algorithms for the SQUID calculations, various statistical properties, and use of the SQUID within the context of a multi-practice quality improvement (QI) project.
Results
At any given time point, the patient-level SQUID reflects the proportion of recommended care received, while the practice-level SQUID reflects the average proportion of recommended care received by that practice's patients. Using quarterly reports, practice- and patient-level SQUIDs are provided routinely to practices within the network. The SQUID is responsive, exhibiting highly significant (p < 0.0001) increases during a major QI initiative, and its internal consistency is excellent (Cronbach's alpha = 0.93). Feedback from physicians has been extremely positive, providing a high degree of face validity.
Conclusion
The SQUID algorithm is feasible and straightforward, and provides a useful QI tool. Its statistical properties and clear interpretation make it appealing to providers, health plans, and researchers.
doi:10.1186/1748-5908-2-11
PMCID: PMC1852570  PMID: 17407560

Results 1-9 (9)