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Implementation science research identifies clinical champions as instrumental in aligning healthcare professionals' (HCPs) behavior with practice guidelines for delivering health services, including vaccinations. However, we know relatively little about identifying or supporting champions. To characterize who vaccine champions are, what they do, and how to support their work in pediatric primary care. In 2022, we interviewed a purposive sample of peer-nominated or self-identified vaccine champions (n=20) and HCPs who worked with vaccine champions (n=4). We thematically analyzed qualitative data. Vaccine champions' defining characteristics were firsthand primary care experience, whether as providers or nursing staff, and a strong belief in vaccinations as uniquely effective tools for primary prevention. Participants noted these beliefs were "part of the DNA" of specialties like pediatrics and infectious disease, where they perceived champions as especially common. Being "insatiable in their quest for knowledge," champions primarily conceptualized their role as understanding and sharing complex information and performance metric data related to vaccine administration. Champions' role in leading other implementation strategies, such as communication training, was more peripheral. Champions reported that dedicated time and staff support helped them "go above and beyond" to improve vaccination rates. Our findings suggest that vaccine champions can be found among providers and nursing staff with deep clinical experience and commitment to primary prevention through vaccination, including through providing vaccine education to colleagues. Healthcare systems can allocate resources to support champions as educators, while exploring opportunities to extend their role in other implementation strategies to improve vaccination rates., (© Society of Behavioral Medicine 2024. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: The COVID-19 pandemic brought about a drastic increase in the utilization of telehealth services in place of or as a complement to in-person health services. Telehealth is a tool to help reduce disparities in the receipt of maternal health care. However, a stable internet connection is required for patients to connect to providers via telehealth; lack of internet connectivity is a barrier to maternal telehealth access. Methods: The objectives of this research were to determine whether community-level internet penetration is associated with community-level utilization of maternal telehealth services and assess the heterogeneity of this association across the maternal telehealth utilization spectrum. A cross-sectional study of community-level maternal telehealth is utilized in the United States in 2019. The underlying population is comprised of commercially insured maternal health patients receiving any antenatal, delivery-related, or postpartum care in the United States. The individual-level utilization data are aggregated to the geo-zip level ( n = 404), which is a regional subdivision comprised of all zip codes that share the first three digits. Results: Findings show that the estimated relationship between the proportion of households with home-based internet connectivity was statistically significant at the 10th and 25th quantiles of maternal telehealth utilization. For these quantiles, an increase in community-level internet connectivity was associated with an increase in the utilization of maternal telehealth services. Conclusion: There is a positive association between community-level internet connectivity and maternal telehealth utilization, and the association varies in magnitude across the maternal telehealth utilization distribution. Policymakers should consider digital access when addressing telehealth policy for maternal care services.

Quality checklists have demonstrated benefits in healthcare and other high-reliability organizations, but there remains a gap in the understanding of design approaches and levels of stakeholder engagement in the development of these quality checklists. This scoping review aims to synthesize the current knowledge base regarding the use of various design approaches for developing quality checklists in healthcare. Secondary objectives are to explore theoretical frameworks, design principles, stakeholder involvement and engagement, and characteristics of the design methods used for developing quality checklists. The review followed the Preferred Reporting Items for Systematic Reviews 2020 checklist. Seven databases (PubMed, APA PsycInfo, CINAHL, Embase, Scopus, ACM Digital Library, and IEEE Xplore) were searched for studies using a comprehensive search strategy developed in collaboration with a health sciences librarian. Search terms included "checklist" and "user-centered design" and their related terms. The IAP2 Spectrum of Participation Framework was used to categorize studies by level of stakeholder engagement during data extraction. Twenty-nine studies met the inclusion criteria for this review. Twenty-three distinct design methods were identified that were predominantly non-collaborative in nature (e.g., interviews, surveys, and other methods that involved only one researcher and one participant at a given time). Analysis of the levels of stakeholder engagement revealed a gap in studies that empowered their stakeholders in the quality checklist design process. Highly effective, clear, and standardized methodology are needed for the design of quality checklists. Future work needs to explore how stakeholders can be empowered in the design process, and how different levels of stakeholder engagement might impact implementation outcomes., Competing Interests: Competing Interests The authors have declared that no competing interests exist.

Background: Academic health centers (AHCs) have traditionally focused on 3 core missions: patient care, research, and education. The current changing health care environment requires AHCs to broaden their focus to improve the health of their communities. This study reports the opportunities and challenges for the 5 North Carolina AHCs addressing social determinants of health (SDOH)., Methods: We used a mixed methods design. We analyzed financial data from systemwide community benefits reports and the Form 990 Schedule H of the primary medical centers (when available) from the 5 AHCs, and we conducted 4 key informant (KI) interviews at each of the 5 AHCs for a total of 20 interviews., Results: Overall, AHCs spend a very small percentage of their total spending on community improvement services and community benefit operations. By far, the largest amount spent on community benefit is for treating patients eligible for charity care. Food insecurity and access to health care were the most addressed SDOH. Housing was viewed as a crisis that needed to be addressed at statewide and national levels., Limitations: Community benefits reports from North Carolina AHCs lack important details. Key informant interviews provide far more recent information on the quantity and breadth of initiatives than the latest community benefits reports that were all completed pre-pandemic. We only interviewed 4 stakeholders from each AHC in North Carolina., Conclusion: A new strategic vision must incorporate social accountability into the AHCs' core missions to remove barriers and institute and sustain change, but the AHCs face a steep challenge to incorporate social accountability at a core mission level., Competing Interests: Acknowledgments: The authors would like to acknowledge Sandra Greene, DrPH; Alexandra Zuber, DrPH; and Michael Flynn, MD, who were part of the dissertation committee for this study. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Disclosure of interests: The authors report no conflict of interest., (Copyright ©2024 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Implementation science emerged from the recognized need to speed the translation of effective interventions into practice. In the US, the science has evolved to place an ever-increasing focus on implementation strategies. The long list of implementation strategies, terminology used to name strategies, and time required to tailor strategies all may contribute to delays in translating evidence-based interventions (EBIs) into practice. To speed EBI translation, we propose a streamlined approach to classifying and tailoring implementation strategies., Main Text: A multidisciplinary team of eight scholars conducted an exercise to sort the Expert Recommendations for Implementing Change (ERIC) strategies into three classes: implementation processes (n = 25), capacity-building strategies (n = 20), and integration strategies (n = 28). Implementation processes comprise best practices that apply across EBIs and throughout the phases of implementation from exploration through sustainment (e.g., conduct local needs assessment). Capacity-building strategies target either general or EBI-specific knowledge and skills (e.g., conduct educational meetings). Integration strategies include "methods and techniques" that target barriers or facilitators to implementation of a specific EBI beyond those targeted by capacity building. Building on these three classes, the team collaboratively developed recommendations for a pragmatic, five-step approach that begins with the implementation processes and capacity-building strategies practice-settings are already using prior to tailoring integration strategies. A case study is provided to illustrate use of the five-step approach to tailor the strategies needed to implement a transitional care intervention in skilled nursing facilities., Conclusions: Our proposed approach streamlines the formative work required prior to implementing an EBI by building on practice partner preferences, expertise, and infrastructure while also making the most of prior research findings., (© 2024. The Author(s).)

Objective: The objective was to estimate the rural-urban differences in the receipt of prepregnancy, prenatal, and postpartum services., Methods: The authors conducted a cross-sectional data analysis using data from the Pregnancy Risk Assessment and Monitoring System from 2016 to 2018 to analyze rural-urban differences in the receipt of medical visits and care content delivery during the prepregnancy year, as well as the prenatal and postpartum periods among birthing people in the US, using survey-weighted multivariable logistic regression models., Results: Rural-dwelling birthing people were significantly less likely to attend a medical visit in the prepregnancy year or postpartum period, even when controlled for sociodemographic and clinical characteristics. Compared to their urban counterparts, they were also less likely to receive comprehensive screening and counseling in the prepregnancy and postpartum maternity phases., Conclusion: Efforts to ameliorate rural-urban differences in maternal care access and quality should explicitly adopt multilevel, systemic approaches to policy and program implementation and evaluation. Policymakers and practitioners should consider telehealth as a potential complementary tool to minimize gaps in quality of care which disproportionately impact rural-dwelling birthing people., Competing Interests: Conflicts of InterestNone declared

Background: Differential access to healthcare is associated with disparities in maternal outcomes. Telehealth is one approach for improving access to maternal services. However, little is known regarding how health systems leverage telehealth to close the access gap., Objective: This study examines how health systems have approached decisions about using telehealth for maternal services before and during the COVID-19 public health emergency and what factors were considered., Methods: We conducted semi-structured interviews with 15 health system leaders between July and October 2021 and June and August 2022. We used a rapid analysis followed by a content analysis approach., Results: Five health systems did not provide maternal telehealth services before the PHE due to a lack of reimbursement. Two health systems provided limited services as research endeavors, and one had integrated telehealth into routine maternity care. During the PHE, all transitioned to telehealth, with the primary consideration being patient and staff safety. At the time of the interview, key considerations shifted to patient access, patient preferences, patient complexity, return on investment, and staff burnout. However, several barriers impacted telehealth use, including coverage of portable devices and connectivity. These issues were reported to be common among underinsured, low-income, and rural patients. Health systems with particularly advanced capabilities worked on approaches to fill access gaps for these patients., Conclusion: Some health systems prioritized telehealth to improve access to high-quality maternal services for patients at the highest risk of adverse outcomes. However, policy and patient-level barriers to equitable implementation of these services persist., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Background: Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care., Methods: In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates.", Results: Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001)., Conclusions: Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions., (© 2024. The Author(s).)

Objective: This study aimed to describe perspectives from stakeholders involved in the Medicaid system in North Carolina regarding substance use disorder (SUD) treatment policy changes during the coronavirus disease 2019 pandemic., Methods: We conducted semistructured interviews in early 2022 with state agency representatives, Medicaid managed care organizations, and Medicaid providers (n = 22) as well as 3 focus groups of Medicaid beneficiaries with SUD (n = 14). Interviews and focus groups focused on 4 topics: policies, meeting needs during COVID, demand for SUD services, and staffing., Results: Overall, policy changes, such as telehealth and take-home methadone, were considered beneficial, with participants displaying substantial support for both policies. Shifting demand for services, staffing shortages, and technology barriers presented significant challenges. Innovative benefits and services were used to adapt to these challenges, including the provision of digital devices and data plans to improve access to telehealth., Conclusions: Perspectives from Medicaid stakeholders, including state organizations to beneficiaries, support the continuation of SUD policy changes that occurred. Staffing shortages remain a substantial barrier. Based on the participants' positive responses to the SUD policy changes made during the coronavirus disease 2019 pandemic, such as take-home methadone and telehealth initiation of buprenorphine, these changes should be continued. Additional steps are needed to ensure payment parity for telehealth services., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 American Society of Addiction Medicine.)

Introduction: Quality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and delivering collaborative content. In partnership with a clinically integrated network, we evaluated implementation outcomes for a virtual QIC with independent primary care practices delivered during COVID-19., Methods: We conducted a longitudinal case study evaluation of a virtual QIC in which practices participated in bimonthly online meetings and monthly tailored QI coaching sessions from July 2020 to June 2021. Implementation outcomes included: (1) level of engagement (meeting attendance and poll questions), (2) QI capacity (assessments completed by QI coaches), (3) use of QI tools (plan-do-check-act (PDCA) cycles started and completed) and (4) participant perceptions of acceptability (interviews and surveys)., Results: Seven clinics from five primary care practices participated in the virtual QIC. Of the seven sites, five were community health centres, three were in rural counties and clinic size ranged from 1 to 7 physicians. For engagement, all practices had at least one member attend all online QIC meetings and most (9/11 (82%)) poll respondents reported meeting with their QI coach at least once per month. For QI capacity, practice-level scores showed improvements in foundational, intermediate and advanced QI work. For QI tools used, 26 PDCA cycles were initiated with 9 completed. Most (10/11 (91%)) survey respondents were satisfied with their virtual QIC experience. Twelve interviews revealed additional themes such as challenges in obtaining real-time data and working with multiple electronic medical record systems., Discussion: A virtual QIC conducted with independent primary care practices during COVID-19 resulted in high participation and satisfaction. QI capacity and use of QI tools increased over 1 year. These implementation outcomes suggest that virtual QICs may be an attractive alternative to engage independent practices in QI work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Despite the policy recommendation and effectiveness of administering the hepatitis B birth-dose vaccine (HepB-BD) to newborns to prevent mother-to-child hepatitis B transmission, timely uptake remains an issue. Countries adopting the HepB-BD to their national immunization schedule report programmatic challenges to administering the vaccine within the recommended 24-hour window after delivery. Further, while the World Health Organization recommends streamlining three birth-dose vaccines (HepB-BD, BCG, and OPV0), scarce Sub-Saharan(SSA)-based literature reports on a streamlined and timely approach to birth-dose vaccines. As more SSA countries adopt the new birth-dose vaccine to their immunization schedules, a systematically developed implementation strategy-Vaccination of Newborns-Innovative Strategies to Hasten Birth-Dose vaccines' delivery (VANISH-BD)-will facilitate the adoption and implementation of timely birth-dose vaccine uptake. In this paper, we describe the development of the implementation strategy using intervention mapping, an evidence-based and theory-driven approach. We report on the development of our intervention, beginning with the needs assessment based in Kinshasa Province, Democratic Republic of the Congo (DRC), informing step 1 of intervention mapping. The intervention is contextually relevant, locally produced, sustainable, and designed to improve timely birth-dose vaccine uptake in the DRC. We intend to inform future implementers about improving timely and streamlined birth-dose vaccine uptake and for VANISH-BD to be adapted for similar contexts., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Boisson-Walsh et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Relatively little is known about the proportion of maternal health services utilized through telehealth and whether rural-urban disparities in telehealth use exist throughout antenatal, delivery, and postpartum phases of maternal services. In this study, we describe patterns of care, including telehealth utilization, by rurality and racial/ethnic composition of the health service area during the antenatal, labor/delivery, and postpartum stages of pregnancy among commercially insured patients between 2016 and 2019. Methods: We present univariate and comparative descriptive statistics of patient and facility characteristics and site of care by the degree of rurality and racial/ethnic composition of the health service area (defined as geozips). The individual-level utilization data for 238,695 patients were aggregated to the geo-zip level ( n  = 404). Results: Between 2016 and 2019, 3.5% of pregnancy, delivery, and postpartum-related visits among commercially insured patients were delivered through telehealth. Telehealth use was higher in the antenatal (3.5% of claim lines) and postpartum (4.1% of claim lines) periods, compared with labor and delivery (0.7% of claim lines). We also found that the proportion of telehealth services (of total services billed) increased with the share of Black and Latinx residents at the geozip level. Discussion: Our findings highlight disparities in telehealth use, consistent with findings from studies using different data sources and time periods. Future research is needed to examine whether the relative differences in proportion of telehealth services, even if small, are associated with telehealth capacity in the hospital or community and why the proportion of telehealth services differs across community-level characteristics, specifically rurality and proportion of Black and Latinx residents.

Background: Despite global efforts to reduce preventable childhood illness by distributing infant vaccines, immunization coverage in sub-Saharan African settings remains low. Further, timely administration of vaccines at birth-tuberculosis (Bacille Calmette-Guérin [BCG]) and polio (OPV0)-remains inconsistent. As countries such as Democratic Republic of the Congo (DRC) prepare to add yet another birth-dose vaccine to their immunization schedule, this study aims to improve current and future birth-dose immunization coverage by understanding the determinants of infants receiving vaccinations within the national timeframe., Methods: The study used two ordered regression models to assess barriers to timely BCG and first round of the hepatitis B (HepB3) immunization series across multiple time points using the Andersen Behavioral Model to conceptualize determinants at various levels. The assessment leveraged survey data collected during a continuous quality improvement study (NCT03048669) conducted in 105 maternity centers throughout Kinshasa Province, DRC. The final sample included 2398 (BCG analysis) and 2268 (HepB3 analysis) women-infant dyads living with HIV., Results: Between 2016 and 2020, 1981 infants (82.6%) received the BCG vaccine, and 1551 (68.4%) received the first dose of HepB3 vaccine. Of those who received the BCG vaccine, 26.3%, 43.5%, and 12.8% received BCG within 24 h, between one and seven days, and between one and 14 weeks, respectively. Of infants who received the HepB3 vaccine, 22.4% received it within six weeks, and 46% between six and 14 weeks of life. Many factors were positively associated with BCG uptake, including higher maternal education, household wealth, higher facility general readiness score, and religious-affiliated facility ownership. The factors influencing HepB3 uptake included older maternal age, higher education level, household wealth, transport by taxi to a facility, higher facility general and immunization readiness scores, and religious-affiliated facility ownership., Conclusions: This study demonstrated that the study participants' uptake of vaccines was consistent with the country average, but not in a timely manner. Various factors were associated with timely uptake of BCG and HepB3 vaccines. These findings suggest that investment to strengthen the vaccine delivery system might improve timely vaccine uptake and equity in vaccine coverage., (© 2023. The Author(s).)

Interprofessional teamwork plays a key role in the uptake of evidence-based interventions, such as noninvasive ventilation (NIV) for patients with exacerbated Chronic Obstructive Pulmonary Disease (COPD). We aimed to identify the shared cognitive tasks in interprofessional teams using NIV for patients with COPD exacerbation. We used a cognitive task analysis approach (CTA) to engage nurses, rapid response team members, respiratory therapists, and physicians involved in the use of NIV to treat patients with COPD exacerbation. Clinicians participated in a semi-structured interview ( n = 21) that elicited cognitions needed to treat COPD exacerbation. Three shared cognitive tasks were identified: Complete a thorough assessment, Formulate a care plan, and Continuously monitor patient status. Findings attest to the importance of having access to up-to-date information and expertise necessary to make accurate clinical inferences for patient assessment. Shared understanding of the formulated care plan among all members of the care team was important to its execution. Continuous monitoring was crucial; however, this cognitive task relied on patient assessment skills and ongoing collaboration within the clinical care team. Application of NIV for patients with COPD exacerbation may require enhancing collaboration through nontechnical skills and interprofessional training.

Background: Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST., Methods: In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters.", Results: Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption., Conclusions: To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption., Trial Registration: ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Introduction: Telestroke has been shown to be a cost-effective approach to promoting use and timeliness of evidence-based treatment. However, adoption of telestroke has been relatively low. Several barriers to telestroke implementation have been previously identified in the literature. These barriers, and the strategies needed to overcome them, may vary across hospitals. Our study aimed to examine telestroke programs to identify opportunities for future research and efforts to promote effective implementation and sustainment of telestroke services. Methods: We surveyed hospitals in five states to capture information about the current status of the hospital's telestroke program; the model(s) of delivery being used (e.g., hub-and-spoke and third-party vendor); and telestroke infrastructure, processes, and implementation strategies. The survey included both closed-ended and open-ended response options. Descriptive results are presented, complemented with illustrative examples of open-ended responses. Results: We received 89 responses, each representing a different hospital. Approximately one-third of telestroke programs in our sample began between 2018 and 2020. More than two-thirds reported participating in a collaboration with other organizations to improve telestroke services. The most commonly reported, high-priority topics for additional guidance involved monitoring process measures, using performance indicators for improvement, and sharing data from measures with physicians. Discussion: Results complement prior studies, specifically about impacts of COVID-19 on telestroke programs and capabilities that hospitals most need assistance with. Challenges faced and guidance needed differ across hospitals, suggesting a need for a tailored support. The results also suggest more work is needed to understand factors that threaten sustainability of telestroke programs.

Background: Practice facilitators (PFs) provide tailored support to primary care practices to improve the quality of care delivery. Often used by PFs, the "Key Driver Implementation Scale" (KDIS) measures the degree to which a practice implements quality improvement activities from the Chronic Care Model, but the scale's psychometric properties have not been investigated. We examined construct validity, reliability, floor and ceiling effects, and a longitudinal trend test of the KDIS items in the Southeastern Collaboration to Improve Blood Pressure Control trial., Methods: The KDIS items assess a practice's progress toward implementing: a clinical information system (using their own data to drive change); standardized care processes; optimized team care; patient self-management support; and leadership support. We assessed construct validity and estimated reliability with a multilevel confirmatory factor analysis (CFA). A trend test examined whether the KDIS items increased over time and estimated the expected number of months needed to move a practice to the highest response options., Results: PFs completed monthly KDIS ratings over 12 months for 32 primary care practices, yielding a total of 384 observations. Data was fitted to a unidimensional CFA model; however, parameter fit was modest and could be improved. Reliability was 0.70. Practices started scoring at the highest levels beginning in month 5, indicating low variability. The KDIS items did show an upward trend over 12 months (all p < .001), indicating that practices were increasingly implementing key activities. The expected time to move a practice to the highest response category was 9.1 months for standardized care processes, 10.2 for clinical information system, 12.6 for self-management support, 13.1 for leadership, and 14.3 months for optimized team care., Conclusions: The KDIS items showed acceptable reliability, but work is needed in larger sample sizes to determine if two or more groups of implementation activities are being measured rather than one., Competing Interests: AMS has received unrelated consulting fees or speaking honoraria from Navigating Cancer, Association of Community Cancer Centers, Genentech, Pfizer, and Henry Ford Cancer Center. ALC has received unrelated consulting fees from Bayer. MMS has unrelated consulting fees from Amgen. She is also part owner of PALS, Inc. a digital health platform. No conflict of interest: MW, CMS, ER, JR, DMC, LN, SP, MC, MM, JRH.

Context: Guidelines recommend palliative care for patients with chronic kidney disease (CKD), who experience a high pain and symptom burden, and receive intensive treatments that often do not align with their values. A lack of scalable specialty palliative care services has prompted calls for attention to primary palliative care, delivered in primary care and nephrology settings., Objectives: The objectives of this study were to 1) describe expectations for care to meet the palliative care needs of people living with CKD, and limitations to meeting those expectations in the current model, and 2) identify potential interventions to meet patients' palliative care needs., Methods: We conducted semi-structured interviews with clinicians from primary care, nephrology, and palliative care to assess 1) reasonable expectations for meeting palliative needs, 2) barriers to integrating primary palliative care, and 3) potential intervention points., Results: Clinicians discussed their expectations for high-quality communication (e.g., discussing disease understanding, assessing goals of care) and better integration of palliative care services. Clinicians expressed barriers to delivering that care, including poor inter-clinician communication. To address barriers, clinicians outlined potential intervention points, such as building collaborative models of care, and structural triggers to identify patients who may be appropriate for palliative care., Conclusion: Interventions to address gaps in palliative care delivery for people living with CKD should incorporate systematic identification of patients with palliative care needs and structural mechanisms to meeting those needs via specialty and primary palliative care., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Low retention is a persistent challenge in the delivery of buprenorphine treatment for opioid use disorder (OUD). The goal of this study was to identify provider factors that could drive differences in treatment retention while accounting for the contribution of patient characteristics to retention., Methods: We developed a novel a mixed-methods approach to explore provider factors that could drive retention while accounting for patient characteristics. We used Medicaid claims data from North Carolina in the United States to identify patient characteristics associated with higher retention. We then identified providers who achieved high and low retention rates. We matched high- and low-retention providers on their patients' characteristics. This matching created high- and low-retention provider groups whose patients had similar characteristics. We then interviewed providers while blinded to which belonged in the high- and low-retention groups on aspects of their practice that could affect retention rates, such as treatment criteria, treatment cost, and services offered., Results: Less than half of patients achieved 180-day treatment retention with large differences by race and ethnicity. We did not find evidence that providers who achieved higher retention consistently did so by providing more comprehensive services or selecting for more stable patients. Rather, our findings suggest use of "high-threshold" clinical approaches, such as requiring participation in psychosocial services or strictly limiting dosages, explain differences in retention rates between providers whose patients have similar characteristics. All low-retention providers interviewed used a high-threshold practice compared to half of high-retention providers interviewed. Requiring patients to participate in psychosocial services, which were often paid out-of-pocket, appeared to be especially important in limiting retention., Conclusion: Providers who adopt low-threshold approaches to treatment may achiever higher retention rates than those who adopt high-threshold approaches. Addressing cost barriers and systemic racism are likely also necessary for improving buprenorphine treatment retention., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Introduction: To examine trends in telemedicine adoption for stroke and cardiac care among U.S. hospitals, specifically associations between hospital financial indicators and adoption of these telemedicine services. Methods: This is a retrospective analysis of data from the Health Information Management and System Society Dorenfest Database and Healthcare Cost Report Information System from 2012 to 2017. We used a pooled ordinary least squares model and reported results as average marginal effects (AMEs). Results: The number of hospitals with stroke or cardiac telemedicine services in urban and rural areas increased through our study period from 153 (7.30%) to 407 (19.42%) and from 127 (6.31%) to 331 (16.45%), respectively. In rural hospitals, being a for-profit hospital (AME = -10.49, 95% confidence interval [CI] = -14.01 to -6.98) and having an increase in Medicare inpatient mix (AME = -0.31, 95% CI = -0.42 to -0.20) were associated with the probability of telemedicine adoption for heart attack and stroke care. A couple of nonfinancial variables included in the model also were associated with adoption, specifically having one more licensed bed (AME = -0.02, 95% CI = -0.04 to -0.00) and higher number of emergency department visits (AME = 5.64, 95% CI = 2.83 to 7.20). In urban hospitals, being a for-profit hospital (AME = -8.94, 95% CI = -11.76 to -6.11) and having a higher total margin (AME = 0.17, 95% CI = 0.08 to 0.26) were associated with the probability of telemedicine adoption for heart attack and stroke care. Two nonfinancial variables also were statistically significant: having one more licensed bed (AME = 0.01, 95% CI = 0.041 to 0.02) and being closer to another telemedicine hospital (AME = 0.81, 95% CI = -1.62 to 0.01). Discussions: Telemedicine adoption rate for cardiac and stroke care has increased significantly in recent years. Financial status may be a bigger driver of adoption for urban hospitals than rural hospitals.

Prolonged high-fat diet (HFD) accelerates the cardiovascular, renal, and metabolic dysfunction in hypertensive rats with altered renal development (ARDev). Soluble guanylate cyclase (sGC) stimulation or sodium-glucose cotransporter 2 (SGLT2) inhibition may improve cardiovascular, renal, and metabolic function in settings of hypertension and obesity. This study examined whether 6 wk treatment with an SGLT2 inhibitor (empagliflozin, 7 mg/kg/day) enhances the cardiovascular, renal, and metabolic effects of a sGC stimulator (praliciguat, 10 mg/kg/day) in hypertensive rats with ARDev and prolonged exposure to HFD. Arterial pressure (AP), renal vascular resistance (RVR), fat abdominal volume (FAV), insulin resistance, leptin and triglycerides levels, and intrarenal infiltration of inflammatory cells were higher, but cardiac output and creatinine clearance were lower in hypertensive rats ( n = 15) than in normotensive rats ( n = 7). Praliciguat administration ( n = 10) to hypertensive rats reduced ( P < 0.05) AP, FAV, plasma concentrations of leptin and triglycerides, and increased ( P < 0.05) cardiac output and creatinine clearance. Empagliflozin administration ( n = 8) only increased ( P < 0.05) glucosuria and creatinine clearance and decreased ( P < 0.05) plasma leptin and triglycerides concentrations in hypertensive rats. Simultaneous administration of praliciguat and empagliflozin ( n = 10) accelerated the decrease in AP, improved glucose tolerance, reduced ( P < 0.05) incremental body weight gain, and decreased ( P < 0.05) insulin resistance index, RVR, and the infiltration of T-CD3 lymphocytes in renal cortex and renal medulla. In summary, the combined administration of praliciguat and empagliflozin leads to a greater improvement of the cardiovascular, renal, and metabolic dysfunction secondary to prolonged exposure to HFD in hypertensive rats with ARDev than the treatment with either praliciguat or empagliflozin alone. NEW & NOTEWORTHY This is the first study, to our knowledge, showing that SGLT2 inhibition potentiates the beneficial cardiovascular, renal, and metabolic effects elicited by sGC stimulation in hypertensive rats with prolonged high-fat diet. The effects of the simultaneous administration of praliciguat and empagliflozin are greater than those elicited by either one alone. The effects of the simultaneous treatment may be related to a greater reduction in the inflammatory status.

Introduction: The coronavirus 2019 pandemic (COVID-19) has resulted in major changes in lifestyle practices and healthcare delivery. The goal of this study was to examine changes in practice and service outcomes in a telehealth program before and after the federal and private telehealth policy expansion during the COVID-19 pandemic. These findings are particularly useful to understand what may be needed to overcome telehealth challenges in future disasters., Methods: We conducted a cross-sectional analysis of virtual visits through a statewide telehealth center embedded in a large academic healthcare system. Primary outcomes of this study were changes in telehealth visits pre- and post-policy expansions among at-risk populations., Results: A total of 2,132 telehealth visits were conducted: 1,530 (71.8 percent) patients were female, 1,561 (73.2 percent) were between the ages 18-50, 1,576 (74 percent) were uninsured, and 1,225 (57.5 percent) were from rural regions. The average number of telehealth visits per day increased from 14 to 33 visits post-expansion. A significant change in patient characteristics was found among senior, uninsured, and rural patients after the telehealth expansion.There was an 11 percent decrease in telehealth visits from very high vulnerability regions post-expansion compared to pre-expansion. There was a 15 percent decrease in visits resulting in prescription post-expansion (p-value<0.01)., Conclusions: COVID-19 policy expansions expanded telehealth utilization among at-risk populations such as senior, uninsured, and rural patients while decompressing hospitals and emergency rooms and maintaining positive patient experiences. Further regulations are needed around virtual visits unintended consequences, software certification, and guidelines for workforce training., (Copyright © 2022 by the American Health Information Management Association.)

Praliciguat is a soluble guanylate cyclase stimulator that elicits hemodynamic, anti-inflammatory, and antifibrotic effects in preclinical models of metabolic dysfunction. We assessed the metabolic effects of praliciguat in a mouse diet-induced obesity (DIO) model housed at thermoneutrality. At 6 weeks old, male C57BL/6N mice were either maintained on low-fat diet (LFD, lean mice) or placed on 60% high-fat diet (HFD, DIO mice). At 14 weeks old, the DIO mice were either maintained on HFD or switched to HFD with praliciguat (6-mg/kg). Day 28 samples were collected for biomarker analysis. In a second study under the same paradigm, indirect calorimetry was performed on days 8, 9, 20, 21, 32, and 33 and an oral lipid tolerance test (LTT) on day 38. Mice treated 28 days with praliciguat had lower levels of fasting plasma insulin, C-peptide, triglycerides, and HOMA-IR (homeostatic model assessment for insulin resistance) than DIO controls. In addition, energy expenditure was higher in praliciguat-treated than in DIO control mice on days 9, 20, 32, and 33; and day-38 triglycerides were lower. HFD-induced increases in gene expression of liver TNF-ɑ, lipoprotein lipase ( Lpl ), and patatin-like phospholipase domain-containing protein 3 ( Pnpla3 ) in control DIO mice were attenuated in praliciguat-treated DIO mice. The positive metabolic effects observed in praliciguat-treated mice were associated with the restoration of liver PI3K (pAKT-Thr308) signaling, but not MAPK (pERK). In conclusion, praliciguat-treated DIO mice had increased energy utilization, improved insulin sensitivity, and lower plasma triglycerides. These results illustrate metabolic effects associated with praliciguat treatment in DIO mice., Competing Interests: Authors CS, JH, GL, PG, CS, EB, and JJ were employed by the company Cyclerion Therapeutics. Author JR was employed by the company Biomeostasis., (Copyright © 2022 Schwartzkopf, Hadcock, Liu, Germano, Roux, Shea, Buys and Jones.)

Objective: To determine if individuals newly diagnosed with opioid use disorder (OUD) who saw a primary care provider (PCP) before or on the date of diagnosis had higher rates of medication treatment for OUD (MOUD)., Methods: Observational study using logistic regression with claims data from Medicaid and a large private insurer in North Carolina from January 2014 to July 2017., Key Results: Between 2014 and 2017, the prevalence of diagnosed OUD increased by 47% among Medicaid enrollees and by 76% among the privately insured. Over the same time period, the percent of people with an OUD who received MOUD fell among both groups, while PCP involvement in treatment increased. Of Medicaid enrollees receiving buprenorphine, the percent receiving buprenorphine from a PCP increased from 32% in 2014 to 39% in 2017. Approximately 82% of people newly diagnosed with OUD had a PCP visit in the 12 months before diagnosis in Medicaid and private insurance. Those with a prior PCP visit were not more likely to receive MOUD. Seeing a PCP at diagnosis was associated with a higher probability of receiving MOUD than seeing an emergency provider but a lower probability than seeing a behavioral health specialist or other provider type., Conclusions: People newly diagnosed with OUD had high rates of contact with PCPs before diagnosis, supporting the importance of PCPs in diagnosing OUD and connecting people to MOUD. Policies and programs to increase access to MOUD and improve PCPs' ability to connect people to evidence-based treatment are needed., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Background: This study brings a human-centered design (HCD) perspective to understanding the patient experience when using noninvasive ventilation (NIV) with the goal of creating better strategies to improve NIV comfort and tolerance., Methods: Using an HCD motivational approach, we created a semi-structured interview to uncover the patients' journey while being treated with NIV. We interviewed 16 patients with chronic obstructive pulmonary disease (COPD) treated with NIV while hospitalized. Patients' experiences were captured in a stepwise narrative creating a journey map as a framework describing the overall experience and highlighting the key processes, tensions, and flows. We broke the journey into phases, steps, emotions, and themes to get a clear picture of the overall experience levers for patients., Results: The following themes promoted NIV tolerance: trust in the providers, the favorable impression of the facility and staff, understanding why the mask was needed, how NIV works and how long it will be needed, immediate relief of the threatening suffocating sensation, familiarity with similar treatments, use of meditation and mindfulness, and the realization that treatment was useful. The following themes deterred NIV tolerance: physical and psychological discomfort with the mask, impaired control, feeling of loss of control, and being misinformed., Conclusions: Understanding the reality of patients with COPD treated with NIV will help refine strategies that can improve their experience and tolerance with NIV. Future research should test ideas with the best potential and generate prototypes and design iterations to be tested with patients., (JCOPDF © 2022.)

Background: There is strong evidence that noninvasive ventilation (NIV) improves the outcomes of patients hospitalized with severe COPD exacerbation, and NIV is recommended as the first-line therapy for these patients. Yet, several studies have demonstrated substantial variation in NIV use across hospitals, leading to preventable morbidity and mortality. In addition, prior studies suggested that efforts to increase NIV use in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, our initial project aimed to compare two educational strategies: online education (OLE) and interprofessional education (IPE), which targets complex team-based care in NIV delivery. Due to the impact of the COVID-19 pandemic on recruitment and planned intervention, we had made several changes in the study design, statistical analysis, and implementation strategies delivery as outlined in the methods., Methods: We originally proposed a two-arm, pragmatic, cluster, randomized hybrid implementation-effectiveness trial comparing two education strategies to improve NIV uptake in patients with severe COPD exacerbation in 20 hospitals with a low baseline rate of NIV use. Due to logistical constrains and slow recruitment, we changed the study design to an opened cohort stepped-wedge design with three steps which will allow the institutions to enroll when they are ready to participate. Only the IPE strategy will be implemented, and the education will be provided in an online virtual format. Our primary outcome will be the hospital-level risk-standardized NIV proportion for the period post-IPE training, along with the change in rate from the period prior to training. Aim 1 will compare the change over time of NIV use among patients with COPD in the step-wedged design. Aim 2 will explore the mediators' role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and effectiveness. Finally, in Aim 3, through interviews with providers, we will assess the acceptability and feasibility of the educational training., Conclusion: The changes in study design will result in several limitation. Most importantly, the hospitals in the three cohorts are not randomized as they enroll based on their readiness. Second, the delivery of the IPE is virtual, and it is not known if remote education is conducive to team building. However, this study will be among the first to test the impact of IPE in the inpatient setting carefully and may generalize to other interventions directed to seriously ill patients., Trial Registration: ClinicalTrials.gov NCT04206735 . Registered on December 20, 2019., (© 2021. The Author(s).)

Background: Screening in primary care for unmet individual social needs (e.g., housing instability, food insecurity, unemployment, social isolation) is critical to addressing their deleterious effects on patients' health outcomes. To our knowledge, this is the first study to apply an implementation science framework to identify implementation factors and best practices for social needs screening and response., Methods: Guided by the Health Equity Implementation Framework (HEIF), we collected qualitative data from clinicians and patients to evaluate barriers and facilitators to implementing the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE), a standardized social needs screening and response protocol, in a federally qualified health center. Eligible patients who received the PRAPARE as a standard of care were invited to participate in semi-structured interviews. We also obtained front-line clinician perspectives in a semi-structured focus group. HEIF domains informed a directed content analysis., Results: Patients and clinicians (i.e., case managers) reported implementation barriers and facilitators across multiple domains (e.g., clinical encounters, patient and provider factors, inner context, outer context, and societal influence). Implementation barriers included structural and policy level determinants related to resource availability, discrimination, and administrative burden. Facilitators included evidence-based clinical techniques for shared decision making (e.g., motivational interviewing), team-based staffing models, and beliefs related to alignment of the PRAPARE with patient-centered care. We found high levels of patient acceptability and opportunities for adaptation to increase equitable adoption and reach., Conclusion: Our results provide practical insight into the implementation of the PRAPARE or similar social needs screening and response protocols in primary care at the individual encounter, organizational, community, and societal levels. Future research should focus on developing discrete implementation strategies to promote social needs screening and response, and associated multisector care coordination to improve health outcomes and equity for vulnerable and marginalized patient populations., (© 2021. The Author(s).)

Background: Health systems are increasingly using standardized social needs screening and response protocols including the Protocol for Responding to and Assessing Patients' Risks, Assets, and Experiences (PRAPARE) to improve population health and equity; despite established relationships between the social determinants of health and health outcomes, little is known about the associations between standardized social needs assessment information and patients' clinical condition., Methods: In this cross-sectional study, we examined the relationship between social needs screening assessment data and measures of cardiometabolic clinical health from electronic health records data using two modelling approaches: a backward stepwise logistic regression and a least absolute selection and shrinkage operation (LASSO) logistic regression. Primary outcomes were dichotomized cardiometabolic measures related to obesity, hypertension, and atherosclerotic cardiovascular disease (ASCVD) 10-year risk. Nested models were built to evaluate the utility of social needs assessment data from PRAPARE for risk prediction, stratification, and population health management., Results: Social needs related to lack of housing, unemployment, stress, access to medicine or health care, and inability to afford phone service were consistently associated with cardiometabolic risk across models. Model fit, as measured by the c-statistic, was poor for predicting obesity (logistic = 0.586; LASSO = 0.587), moderate for stage 1 hypertension (logistic = 0.703; LASSO = 0.688), and high for borderline ASCVD risk (logistic = 0.954; LASSO = 0.950)., Conclusions: Associations between social needs assessment data and clinical outcomes vary by cardiometabolic condition. Social needs assessment data may be useful for prospectively identifying patients at heightened cardiometabolic risk; however, there are limits to the utility of social needs data for improving predictive performance., (© 2021. The Author(s).)

Background: Developing effective implementation strategies requires adequate tracking and reporting on their application. Guidelines exist for defining and reporting on implementation strategy characteristics, but not for describing how strategies are adapted and modified in practice. We built on existing implementation science methods to provide novel methods for tracking strategy modifications., Methods: These methods were developed within a stepped-wedge trial of an implementation strategy package designed to help community clinics adopt social determinants of health-related activities: in brief, an 'Implementation Support Team' supports clinics through a multi-step process. These methods involve five components: 1) describe planned strategy; 2) track its use; 3) monitor barriers; 4) describe modifications; and 5) identify / describe new strategies. We used the Expert Recommendations for Implementing Change taxonomy to categorize strategies, Proctor et al.'s reporting framework to describe them, the Consolidated Framework for Implementation Research to code barriers / contextual factors necessitating modifications, and elements of the Framework for Reporting Adaptations and Modifications-Enhanced to describe strategy modifications., Results: We present three examples of the use of these methods: 1) modifications made to a facilitation-focused strategy (clinics reported that certain meetings were too frequent, so their frequency was reduced in subsequent wedges); 2) a clinic-level strategy addition which involved connecting one study clinic seeking help with community health worker-related workflows to another that already had such a workflow in place; 3) a study-level strategy addition which involved providing assistance in overcoming previously encountered (rather than de novo) challenges., Conclusions: These methods for tracking modifications made to implementation strategies build on existing methods, frameworks, and guidelines; however, as none of these were a perfect fit, we made additions to several frameworks as indicated, and used certain frameworks' components selectively. While these methods are time-intensive, and more work is needed to streamline them, they are among the first such methods presented to implementation science. As such, they may be used in research on assessing effective strategy modifications and for replication and scale-up of effective strategies. We present these methods to guide others seeking to document implementation strategies and modifications to their studies., Trial Registration: clinicaltrials.gov ID: NCT03607617 (first posted 31/07/2018).

Background: Electronic visits (e-visits) involve asynchronous communication between clinicians and patients through a secure web-based platform, such as a patient portal, to elicit symptoms and determine a diagnosis and treatment plan. E-visits are now reimbursable through Medicare due to the COVID-19 pandemic. The state of evidence regarding e-visits, such as the impact on clinical outcomes and health care delivery, is unclear., Objective: To address this gap, we examine how e-visits have impacted clinical outcomes and health care quality, access, utilization, and costs., Methods: We conducted a systematic review; MEDLINE, Embase, and Web of Science were searched from January 2000 through October 2020 for peer-reviewed studies that assessed e-visits' impacts on clinical and health care delivery outcomes., Results: Out of 1859 papers, 19 met the inclusion criteria. E-visit usage was associated with improved or comparable clinical outcomes, especially for chronic disease management (eg, diabetes care, blood pressure management). The impact on quality of care varied across conditions. Quality of care was equivalent or better for chronic conditions, but variable quality was observed in infection management (eg, appropriate antibiotic prescribing). Similarly, the impact on health care utilization varied across conditions (eg, lower utilization for dermatology but mixed impact in primary care). Health care costs were lower for e-visits than those for in-person visits for a wide range of conditions (eg, dermatology and acute visits). No studies examined the impact of e-visits on health care access. It is difficult to draw firm conclusions about effectiveness or impact on care delivery from the studies that were included because many used observational designs., Conclusions: Overall, the evidence suggests e-visits may provide clinical outcomes that are comparable to those provided by in-person care and reduce health care costs for certain health care conditions. At the same time, there is mixed evidence on health care quality, especially regarding infection management (eg, sinusitis, urinary tract infections, conjunctivitis). Further studies are needed to test implementation strategies that might improve delivery (eg, clinical decision support for antibiotic prescribing) and to assess which conditions can be managed via e-visits., (©Oliver T Nguyen, Amir Alishahi Tabriz, Jinhai Huo, Karim Hanna, Christopher M Shea, Kea Turner. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.05.2021.)

Characterization of critical reagents can mitigate adverse impact to ligand-binding assay performance. We investigated the conjugation conditions of a bispecific protein to SULFO-TAG NHS-Ester™ ruthenium to resolve a steady increase in ligand-binding assay background signal. Functional and biophysical attributes in stability samples revealed low pH (4.0) conjugation and formulation buffers were key to decrease aggregate formation. We also identified pH-specific (3.0) purification conditions to reduce aggregate levels from 37% to <5% of a mouse IgG3 reagent antibody. These case studies support the utility of biophysical and functional characterization of critical reagents as a proactive approach to maintain long-term stability and provide the basis for our recommendations a risk-based approach to establish re-evaluation intervals for traditional and novel reagents.

Given their clinical training and accessibility, community pharmacists are well positioned to support primary care, especially in providing medication management services. There is limited evidence, however, on implementation of community pharmacist-led services in coordination with other health care providers. The aim of this study was to examine the implementation process of community pharmacies in North Carolina participating in a Medicaid population health management intervention. We conducted semistructured interviews with 40 representatives from high- and low-performing community pharmacies from June to August 2017. We analyzed for themes organized around Rogers's Stages in the Innovation Process in Organizations. Community pharmacies employed numerous implementation strategies such as developing relationships with providers and redefining job responsibilities to ensure pharmacists and pharmacy technicians are working at the top of their license. Findings also revealed differences in the implementation process among high- and low-performing pharmacies. Continued research is needed to determine which implementation strategies improve program performance.

Purpose: Surgically treated hydrocephalus patients are frequently imaged with head computed tomography (CT), and risk/benefit communication with families is inconsistent and unknown. We aimed to educate patients and caregivers about radiation safety in CT and explore their communication preferences., Methods: We conducted a pediatric CT radiation safety and diagnostic imaging educational workshop for patients and caregivers at a national conference on hydrocephalus to characterize current practice and desired communication about CT imaging. Our workshop consisted of an interactive educational intervention with pre-/post-session surveys followed by feedback from participants., Results: Our session included 34 participants (100% response rate for surveys) with 28 being parents of individuals with hydrocephalus. A total of 76% (n = 26) participants showed an increase in knowledge after the session (p < 0.01). All participants (N = 34) uniformly desired risk/benefit discussions before CT scans. However, 71% stated that they were not informed of risks/benefits of CT scans by a medical professional. Following the session, the number of participants indicating that informed consent should be obtained before CT scans increased from 30 to 33. Respondents also revealed that 14% of children and young adults had received > 100 CT scans for shunt evaluation with the median being 25 scans (IQR 20)., Conclusions: Caregivers desire and deserve to be empowered through education and social support, and continuously engaged through sharing decisions and co-designing care plans. The neurosurgical community is in an ideal position to collaborate with radiologists, primary care providers, and parents in the development and testing of credible, high-quality online and social media resources.

Background: Medication treatment for opioid use disorder (M-OUD) is underutilized, despite research demonstrating its effectiveness in treating opioid use disorder (OUD). The UNC Extension for Community Healthcare Outcomes for Rural Primary Care Medication Assisted Treatment (UNC ECHO for MAT) project was designed to evaluate interventions for reducing barriers to delivery of M-OUD by rural primary care providers in North Carolina. A key element was tele-conferenced sessions based on the University of New Mexico Project ECHO model, comprised of case discussions and didactic presentations using a "hub and spoke" model, with expert team members at the hub site and community-based providers participating from their offices (i.e., spoke sites). Although federal funders have promoted use of the model, barriers for providers to participate in ECHO sessions are not well documented. Methods : UNC ECHO for MAT included ECHO sessions, provider-to-provider consultations, and practice coaching. We conducted 20 semi-structured interviews to assess perceived usefulness of the UNC ECHO for MAT intervention, barriers to participation in the intervention, and persistent barriers to prescribing M-OUD. Results : Participants were generally satisfied with ECHO sessions and provider-to-provider consultations; however, perceived value of practice support was less clear. Primary barriers to participating in ECHO sessions were timing and length of sessions. Participants recommended recording ECHO sessions for viewing later, and some thought incentives for either the practice or provider could facilitate participation. Providers who had participated in ECHO sessions valued the expertise on the expert team; the team's ability to develop a supportive, collegial environment; and the value of a community of providers interested in learning from each other, particularly through case discussions. Conclusions : Despite the perceived value of ECHO, barriers may prevent consistent participation. Also, barriers to M-OUD delivery remain, including some that ECHO alone cannot address, such as Medicaid and private-insurer policies and availability of psychosocial resources.

Purpose: Social determinants of health, including food insecurity, housing instability, social isolation, and unemployment are important drivers of health outcomes and utilization. To inform implementation of social needs screening and response protocols, there is a need to identify the associated costs in routine primary care encounters., Methods: We interviewed key stakeholders in four diverse community health centers that had adopted a widely used social needs screening and response protocol. We evaluated costs using an activity-based costing tool across both the initial implementation phase and ongoing maintenance phase., Results: Clinic costs were associated with workforce development, planning, and electronic health record integration. These initial implementation costs varied by site ($6,644-$49,087). On a per-patient basis, ongoing maintenance costs ranged from $9.76 to $47.98., Conclusion: Our findings can aid in designing reimbursement mechanisms tied to social needs screening and response to accelerate translational efforts and promote health equity.

Background: The importance of having a champion to promote implementation efforts has been discussed in the literature for more than five decades. However, the empirical literature on champions remains underdeveloped. As a result, health organizations commonly use champions in their implementation efforts without the benefit of evidence to guide decisions about how to identify, prepare, and evaluate their champions. The goal of this article is to present a model of champion impact that draws upon previous literature and is intended to inform future research on champions and serve as a guide for practitioners serving in a champion role., Methods: The proposed model is informed by existing literature, both conceptual and empirical. Prior studies and reviews of the literature have faced challenges in terms of operationalizing and reporting on champion characteristics, activities, and impacts. The proposed model addresses this challenge by delineating these constructs, which allows for consolidation of factors previously discussed about champions as well as new hypothesized relationships between constructs., Results: The model proposes that a combination of champion commitment and champion experience and self-efficacy influence champion performance, which influences peer engagement with the champion, which ultimately influences the champion's impact. Two additional constructs have indirect effects on champion impact. Champion beliefs about the innovation and organizational support for the champion affect champion commitment., Conclusion: The proposed model is intended to support prospective studies of champions by hypothesizing relationships between constructs identified in the champion literature, specifically relationships between modifiable factors that influence a champion's potential impact. Over time, the model should be modified, as appropriate, based on new findings from champion-related research., Competing Interests: Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Praliciguat, a clinical-stage soluble guanylate cyclase (sGC) stimulator, increases cGMP via the nitric oxide-sGC pathway. Praliciguat has been shown to be renoprotective in rodent models of hypertensive nephropathy and renal fibrosis. In the present study, praliciguat alone and in combination with enalapril attenuated proteinuria in the obese ZSF1 rat model of diabetic nephropathy. Praliciguat monotherapy did not affect hemodynamics. In contrast, enalapril monotherapy lowered blood pressure but did not attenuate proteinuria. Renal expression of genes in pathways involved in inflammation, fibrosis, oxidative stress, and kidney injury was lower in praliciguat-treated obese ZSF1 rats than in obese control rats; fasting glucose and cholesterol were also lower with praliciguat treatment. To gain insight into how tubular mechanisms might contribute to its pharmacological effects on the kidneys, we studied the effects of praliciguat on pathological processes and signaling pathways in cultured human primary renal proximal tubular epithelial cells (RPTCs). Praliciguat inhibited the expression of proinflammatory cytokines and secretion of monocyte chemoattractant protein-1 in tumor necrosis factor-α-challenged RPTCs. Praliciguat treatment also attenuated transforming growth factor-β-mediated apoptosis, changes to a mesenchyme-like cellular phenotype, and phosphorylation of SMAD3 in RPTCs. In conclusion, praliciguat improved proteinuria in the ZSF1 rat model of diabetic nephropathy, and its actions in human RPTCs suggest that tubular effects may contribute to its renal benefits, building upon strong evidence for the role of cGMP signaling in renal health.

Background: Past studies examining barriers to patient portal adoption have been conducted with a small number of patients and health care settings, limiting generalizability., Objective: This study had the following two objectives: (1) to assess the prevalence of barriers to patient portal adoption among nonadopters and (2) to examine the association between nonadopter characteristics and reported barriers in a nationally representative sample., Methods: Data from this study were obtained from the 2019 Health Information National Trends Survey. We calculated descriptive statistics to determine the most prevalent barriers and conducted multiple variable logistic regression analysis to examine which characteristics were associated with the reported barriers., Results: The sample included 4815 individuals. Among these, 2828 individuals (58.73%) had not adopted a patient portal. Among the nonadopters (n=2828), the most prevalent barriers were patient preference for in-person communication (1810/2828, 64.00%), no perceived need for the patient portal (1385/2828, 48.97%), and lack of comfort and experience with computers (735/2828, 25.99%). Less commonly, individuals reported having no patient portal (650/2828, 22.98%), no internet access (650/2828, 22.98%), privacy concerns (594/2828, 21.00%), difficulty logging on (537/2828, 18.99%), and multiple patient portals (255/2828, 9.02%) as barriers. Men had significantly lower odds of indicating a preference for speaking directly to a provider compared with women (odds ratio [OR] 0.75, 95% CI 0.60-0.94; P=.01). Older age (OR 1.01, 95% CI 1.00-1.02; P<.001), having a chronic condition (OR 1.83, 95% CI 1.44-2.33; P<.001), and having an income lower than US $20,000 (OR 1.61, 95% CI 1.11-2.34; P=.01) were positively associated with indicating a preference for speaking directly to a provider. Hispanic individuals had significantly higher odds of indicating that they had no need for a patient portal (OR 1.59, 95% CI 1.24-2.05; P<.001) compared with non-Hispanic individuals. Older individuals (OR 1.05, 95% CI 1.04-1.06; P<.001), individuals with less than a high school diploma (OR 3.15, 95% CI 1.79-5.53; P<.001), and individuals with a household income of less than US $20,000 (OR 2.78, 95% CI 1.88-4.11; P<.001) had significantly higher odds of indicating that they were uncomfortable with a computer., Conclusions: The most common barriers to patient portal adoption are preference for in-person communication, not having a need for the patient portal, and feeling uncomfortable with computers, which are barriers that are modifiable and can be intervened upon. Patient characteristics can help predict which patients are most likely to experience certain barriers to patient portal adoption. Further research is needed to tailor implementation approaches based on patients' needs and preferences., (©Kea Turner, Alecia Clary, Young-Rock Hong, Amir Alishahi Tabriz, Christopher M Shea. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 17.09.2020.)

Objective: Medical errors in the emergency department (ED) occur frequently. Yet, common adverse event detection methods, such as voluntary reporting, miss 90% of adverse events. Our objective was to demonstrate the use of patient-reported data in the ED to assess patient safety, including medical errors., Methods: Analysis of patient-reported survey data collected over a 1-year period in a large, academic emergency department. All patients who provided a valid e-mail or cell phone number received a brief electronic survey within 24 hours of their ED encounter by e-mail or text message with Web link. Patients were asked about ED safety-related processes., Results: From Aug 2012 to July 2013, we sent 52,693 surveys and received 7103 responses (e-mail response rate 25.8%), including 2836 free-text comments (44% of respondents). Approximately 242 (8.5%) of 2836 comments were classified as potential safety issues, including 12 adverse events, 40 near-misses, 23 errors with minimal risk of harm, and 167 general safety issues (eg, gaps in care transitions). Of the 40 near misses, 35 (75.0%) of 40 were preventable. Of the 52 adverse events or near misses, 5 (9.6%) were also identified via an existing patient occurrence reporting system., Conclusions: A patient-reported approach to assess ED-patient safety yields important, complementary, and potentially actionable safety information.

Nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic 3',5' GMP (cGMP) signaling plays a central role in regulation of diverse processes including smooth muscle relaxation, inflammation, and fibrosis. sGC is activated by the short-lived physiologic mediator NO. sGC stimulators are small-molecule compounds that directly bind to sGC to enhance NO-mediated cGMP signaling. Olinciguat, (R)-3,3,3-trifluoro-2-(((5-fluoro-2-(1-(2-fluorobenzyl)-5-(isoxazol-3-yl)-1H-pyrazol-3-yl)pyrimidin-4-yl)amino)methyl)-2-hydroxypropanamide, is a new sGC stimulator currently in Phase 2 clinical development. To understand the potential clinical utility of olinciguat, we studied its pharmacokinetics, tissue distribution, and pharmacologic effects in preclinical models. Olinciguat relaxed human vascular smooth muscle and was a potent inhibitor of vascular smooth muscle proliferation in vitro . These antiproliferative effects were potentiated by the phosphodiesterase 5 inhibitor tadalafil, which did not inhibit vascular smooth muscle proliferation on its own. Olinciguat was orally bioavailable and predominantly cleared by the liver in rats. In a rat whole body autoradiography study, olinciguat-derived radioactivity in most tissues was comparable to plasma levels, indicating a balanced distribution between vascular and extravascular compartments. Olinciguat was explored in rodent models to study its effects on the vasculature, the heart, the kidneys, metabolism, and inflammation. Olinciguat reduced blood pressure in normotensive and hypertensive rats. Olinciguat was cardioprotective in the Dahl rat salt-sensitive hypertensive heart failure model. In the rat ZSF1 model of diabetic nephropathy and metabolic syndrome, olinciguat was renoprotective and associated with lower circulating glucose, cholesterol, and triglycerides. In a mouse TNFα-induced inflammation model, olinciguat treatment was associated with lower levels of endothelial and leukocyte-derived soluble adhesion molecules. The pharmacological features of olinciguat suggest that it may have broad therapeutic potential and that it may be suited for diseases that have both vascular and extravascular pathologies., (Copyright © 2020 Zimmer, Shea, Tobin, Tchernychev, Germano, Sykes, Banijamali, Jacobson, Bernier, Sarno, Carvalho, Chien, Graul, Buys, Jones, Wakefield, Price, Chickering, Milne, Currie and Masferrer.)

Context: Palliative care aligns treatments with patients' values and improves quality of life, yet whether receipt of recommended elements of palliative care is associated with end-of-life outcomes is understudied., Objectives: To assess whether recommended elements of palliative care (pain and symptom management, goals of care, and spiritual care) precede in-hospital death and hospice referral and whether delivery by specialty palliative care affects that relationship., Methods: We conducted structured chart reviews for decedents with late-stage cancer, dementia, and chronic kidney disease with a hospital admission during the six months preceding death. Measures included receipt of recommended elements of palliative care delivered by any clinician and specialty palliative care consult. We assessed associations between recommended elements of palliative care and in-hospital death and hospice referral using multivariable Poisson regression models., Results: Of 402 decedents, 67 (16.7%) died in hospital, and 168 (41.8%) had hospice referral. Among elements of palliative care, only goals-of-care discussion was associated with in-hospital death (incidence rate ratio [IRR] 1.37; 95% CI 1.01-1.84) and hospice referral (IRR 1.85; 95% CI 1.31-2.61). Specialty palliative care consult was associated with a lower likelihood of in-hospital death (IRR 0.57; 95% CI 0.44-0.73) and a higher likelihood of hospice referral (IRR 1.45; 95% CI 1.12-1.89) compared with no consult., Conclusion: Goals-of-care discussions by different types of clinicians commonly precede end-of-life care in hospital or hospice. However, engagement with specialty palliative care reduced in-hospital death and increased hospice referral. Understanding the causal pathways of goals-of-care discussions may help build primary palliative care interventions to support patients near the end of life., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation., Methods: The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study., Discussion: To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Importance: Persons living with serious illness often need skilled symptom management, communication, and spiritual support. Palliative care addresses these needs and may be delivered by either specialists or clinicians trained in other fields. It is important to understand core elements of palliative care to best provide patient-centered care., Objective: To describe frequency, predictors, and timing of core elements of palliative care during the last 6 months of life., Design: Retrospective chart review., Setting: Inpatient academic medical center., Participants: Decedents with cancer, dementia, or chronic kidney disease (CKD) admitted during the 6 months preceding death., Exposures: We identified receipt and timing of core elements of palliative care: pain and symptom management, goals of care, spiritual care; and specialty palliative care utilization; hospital encounters; demographics; and comorbid diagnoses. We ran Poisson regression models to assess whether diagnosis or hospital encounters were associated with core elements of palliative care., Results: Among 402 decedents, the mean (SD) number of appropriately screened and treated symptoms was 2.9 (1.7)/10. Among 76.1% with documented goals of care, 58.0% had a primary goal of comfort; 55.0% had documented spiritual care. In multivariable models, compared with decedents with cancer, those with dementia or CKD were less likely to have pain and symptom management (respectively, 31% (incidence rate ratio [IRR], 0.69; 95% CI, 0.56-0.85) and 17% (IRR, 0.83; CI, 0.71-0.97)). There was a median of 3 days (IQR, 0-173) between transition to a goal of comfort and death, and a median of 12 days (IQR, 5-47) between hospice referral and death., Conclusions and Relevance: Although a high proportion of patients received elements of palliative care, transitions to a goal of comfort or hospice happened very near death. Palliative care delivery can be improved by systematizing existing mechanisms, including prompts for earlier goals-of-care discussion, symptom screening, and spiritual care, and by building collaboration between primary and specialty palliative care services.

Background: COPD is the fourth leading cause of death in the US, and COPD exacerbations result in approximately 700,000 hospitalizations annually. Patients with acute respiratory failure due to severe COPD exacerbation are treated with invasive (IMV) or noninvasive mechanical ventilation (NIV). Although IMV reverses hypercapnia/hypoxia, it causes significant morbidity and mortality. There is strong evidence that patients treated with NIV have better outcomes, and NIV is recommended as first line therapy in these patients. Yet, several studies have demonstrated substantial variation in the use of NIV across hospitals, leading to preventable morbidity and mortality. Through a series of mixed-methods studies, we have found that successful implementation of NIV requires physicians, respiratory therapists (RTs), and nurses to communicate and collaborate effectively, suggesting that efforts to increase the use of NIV in COPD need to account for the complex and interdisciplinary nature of NIV delivery and the need for team coordination. Therefore, we propose to compare two educational strategies: online education (OLE) and interprofessional education (IPE) which targets complex team-based care in NIV delivery., Methods and Design: Twenty hospitals with low baseline rates of NIV use will be randomized to either the OLE or IPE study arm. The primary outcome of the trial is change in the hospital rate of NIV use among patients with COPD requiring ventilatory support. In aim 1, we will compare the uptake change over time of NIV use among patients with COPD in hospitals enrolled in the two arms. In aim 2, we will explore mediators' role (respiratory therapist autonomy and team functionality) on the relationship between the implementation strategies and implementation effectiveness. Finally, in aim 3, through interviews with providers, we will assess acceptability and feasibility of the educational training., Discussions: This study will be among the first to carefully test the impact of IPE in the inpatient setting. This work promises to change practice by offering approaches to facilitate greater uptake of NIV and may generalize to other interventions directed to seriously-ill patients., Trial Registration: Name of registry: ClinicalTrials.govTrial registration number: NCT04206735Date of Registration: December 20, 2019., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

Reduced nitric oxide (NO) and a decrease in cGMP signaling mediated by soluble guanylate cyclase (sGC) has been linked to the development of several cardiorenal diseases. Stimulation of sGC is a potential means for enhancing cGMP production in conditions of reduced NO bioavailability. The purpose of our studies was to determine the effects of praliciguat, a clinical-stage sGC stimulator, in a model of cardiorenal failure. Dahl salt-sensitive rats fed a high-salt diet to induce hypertension and organ damage were treated with the sGC stimulator praliciguat to determine its effects on hemodynamics, biomarkers of inflammation, fibrosis, tissue function, and organ damage. Praliciguat treatment reduced blood pressure, improved cardiorenal damage, and attenuated the increase in circulating markers of inflammation and fibrosis. Notably, praliciguat affected markers of renal damage at a dose that had minimal effect on blood pressure. In addition, liver fibrosis and circulating markers of tissue damage were attenuated in praliciguat-treated rats. Stimulation of the NO-sGC-cGMP pathway by praliciguat attenuated or normalized indicators of chronic inflammation, fibrosis, and tissue dysfunction in the Dahl salt-sensitive rat model. Stimulation of sGC by praliciguat may present an effective mechanism for treating diseases linked to NO deficiency, particularly those associated with cardiac and renal failure. Praliciguat is currently being evaluated in patients with diabetic nephropathy and heart failure with preserved ejection fraction.

Background: Systematic identification of patients allows researchers and clinicians to test new models of care delivery. EHR phenotypes-structured algorithms based on clinical indicators from EHRs-can aid in such identification., Objective: To develop EHR phenotypes to identify decedents with stage 4 solid-tumor cancer or stage 4-5 chronic kidney disease (CKD)., Design: We developed two EHR phenotypes. Each phenotype included International Classification of Diseases (ICD)-9 and ICD-10 codes. We used natural language processing (NLP) to further specify stage 4 cancer, and lab values for CKD., Subjects: Decedents with cancer or CKD who had been admitted to an academic medical center in the last 6 months of life and died August 26, 2017-December 31, 2017., Main Measure: We calculated positive predictive values (PPV), false discovery rates (FDR), false negative rates (FNR), and sensitivity. Phenotypes were validated by a comparison with manual chart review. We also compared the EHR phenotype results to those admitted to the oncology and nephrology inpatient services., Key Results: The EHR phenotypes identified 271 decedents with cancer, of whom 186 had stage 4 disease; of 192 decedents with CKD, 89 had stage 4-5 disease. The EHR phenotype for stage 4 cancer had a PPV of 68.6%, FDR of 31.4%, FNR of 0.5%, and 99.5% sensitivity. The EHR phenotype for stage 4-5 CKD had a PPV of 46.4%, FDR of 53.7%, FNR of 0.0%, and 100% sensitivity., Conclusions: EHR phenotypes efficiently identified patients who died with late-stage cancer or CKD. Future EHR phenotypes can prioritize specificity over sensitivity, and incorporate stratification of high- and low-palliative care need. EHR phenotypes are a promising method for identifying patients for research and clinical purposes, including equitable distribution of specialty palliative care.

Objectives: To (1) describe the implementation process for comprehensive medication reviews (CMRs) among community pharmacies (e.g., processes for prioritizing patients, staffing, and information collection) and (2) examine factors associated with community pharmacies' CMR information collection process., Methods: A survey was administered to the pharmacist responsible for implementation of CMRs (i.e., the lead pharmacist) in the community pharmacy (n = 87). The survey included questions about pharmacy characteristics, satisfaction with the NC community pharmacy enhanced services network (NC-CPESN) program, and implementation of CMRs. Frequencies and means were calculated to describe the sample characteristics and pharmacies' CMR implementation process. A multiple linear regression was conducted to examine which characteristics were associated with the CMR information collection process., Results: The majority of pharmacies in the sample were either independently owned single stores (46.5%) or multiple stores under the same independent ownership (41.6%). Most pharmacies used pharmacists (97.7%) or pharmacy technicians (65.5%) for patient outreach for CMRs. A small percentage of pharmacies used administrative staff to conduct patient outreach for CMRs (9.2%). Information for prescription medications (89.5%), indication (80%), and medication adherence (81.1%) was routinely collected. Information such as date of last dose for prescription medications (48.4%) and lifestyle factors, such as physical activity (21.1%), diet (29.5%), and alcohol (31.6%), was collected less routinely. Having a clinical pharmacist (P = 0.025) and pharmacist overlap hours (P = 0.009) significantly improved the CMR information collection process., Conclusion: Although CMRs are important interventions for improving patient outcomes, more guidance is needed on how to effectively implement them. This would allow the process to be efficient and assure implementation with fidelity across all community pharmacies. In addition, staffing appears to influence the quality of CMR information collection. Future research is warranted on CMR implementation to develop efficient staffing models and standardize the process of information collection., (Copyright © 2019 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

BACKGROUND Successful diabetes care requires patient engagement and health self-management. Diabetes shared medical appointments (SMAs) are an evidence-based approach that enables peer support, diabetes group education, and medication management to improve outcomes. The purpose of this study is to learn how diabetes SMAs are being delivered in North Carolina, including the characteristics of diabetes SMAs across the state. METHOD Twelve health systems in the state of North Carolina were contacted to explore clinical workflow and intervention characteristics with a member of the SMA care delivery team. Surveys were used to assess intervention characteristics and delivery. RESULTS Diabetes SMAs were offered in 10 clinics in 5 of the 12 health systems contacted with considerable heterogeneity across sites. The majority of SMAs were open cohorts (80%), offered monthly (60%) for 1.5 hours (60%). SMAs included a mean of 7.5 ± 3.4 patients with a maximum of 11.2 ± 2.7 patients. Survey data revealed barriers (cost-sharing and provider buy-in) to, and facilitators (leadership support and clinical champions) of, clinical adoption and sustained implementation. LIMITATIONS External validity is limited due to the small sample size and geographic clustering. CONCLUSION There is significant heterogeneity in the delivery and characteristics of diabetes SMAs in North Carolina with only modest uptake across the health systems. Further research to determine best practices and effectiveness in diverse, real-world clinical settings is required to inform implementation and dissemination efforts., (©2019 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.)

Background: Limited evidence exists on how to integrate community pharmacists into team-based care models, as the inclusion of community pharmacy services into alternative payment models is relatively new. To be successful in team-based care models, community pharmacies need to successfully build relationship with diverse stakeholders including providers, care managers, and patients., Objectives: The aims of this study are to: (1) identify the role of network ties to support implementation of a community pharmacy enhanced services network, (2) describe how these network ties are formed and maintained, and (3) compare the role of network ties among high- and low-performing community pharmacies participating in an enhanced services network., Methods: Using a semi-structured interview guide, we interviewed 40 community pharmacy representatives responsible for implementation of a community pharmacy enhanced services program. We analyzed for themes using social network theory to compare network ties among 24 high- and 16 low-performing community pharmacies., Results: The study found that high-performing pharmacies had a greater diversity of network ties (e.g., relationships with healthcare providers, care managers, and public health agencies). High-performing pharmacies were able to use those ties to support implementation of NC-CPESN. High- and low-performing pharmacies used similar strategies for establishing ties with patients, such as motivational interviewing and assigning staff members to be responsible for engaging high-risk patients. High-performing pharmacies used additional strategies such as assessing patient preferences to support patient engagement, increasing patient receptivity towards enhanced services., Conclusions: Community pharmacies may vary in their ability to develop relationships with other healthcare providers, care management and public agencies, and patients. As enhanced services interventions that require care coordination are scaled up and spread, additional research is needed to test implementation strategies that support community pharmacies with developing and maintaining relationships across a diverse group of stakeholders (e.g., healthcare providers, care managers, public health agencies, patients)., (Copyright © 2018. Published by Elsevier Inc.)