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Biomedical subjects

Edward H Wagner

Publications and source records attributed to Edward H Wagner.

At least 19 recordsLinked to original sources
PubMed2006

Transform residency training in chronic illness care -- now.

Identification of the drivers of change that hasten improvement of chronic illness care in resident practices serves as an effective strategy for transformative change. The Academic Chronic Care Collaborative (ACCC) is an ongoing network of 48 teams from 22 teaching hospitals and systems that have committed to implementation of the evidence-based Chronic Care Model in their residency practices. The teams track the results of their efforts by monthly reports of both clinical and educational outcomes. The authors' experience with these self-selected teams shows that the two most effective drivers of change have been organization-wide leadership -- from the CEO to the clinical manager -- and the academic culture, e.g., competitiveness, the aspiration for excellence, focus on the research mission, comfort with data, and commitment to the education mission. These ACCC teams and their sponsoring health systems have successfully harnessed these drivers for the implementation of evidence-based chronic illness care in resident practices.

Academic Medical Centers↗
PubMed2005

Applying depression-specific change concepts in a collaborative breakthrough series.

BACKGROUND: Twenty ethnically and geographically diverse health care organizations, including 15 Bureau of Primary Health Care centers, participated in an Institute for Healthcare Improvement (IHI) collaborative Breakthrough Series (BTS) project on depression. Teams attended three learning sessions that emphasized the chronic illness care model, key depression change concepts, and how to initiate plan-do-study-act cycles. RESULTS: Seventeen of the 20 organizations completing the BTS achieved a faculty assessment of at least a 4 (5 indicates significant improvement). More than 2000 patients initiated depression treatment and were registered in the plan's depression registries. Patients in the centers who used the recommended measures had the following outcomes: 56% had significant change in their depressive symptoms at 12 weeks, 87% completed follow-up assessments, 54% continued antidepressant medication for at least 10 weeks, and 90% completed a structured diagnostic assessment before treatment. DISCUSSION: On the basis of the feedback from ten successful teams, the essential change concepts for depression were establishing and maintaining a patient registry, care coordination, diagnostic assessment, and proactive follow-up. Many of the BTS centers have continued to expand their depression treatment programs. The IHI BTS appears to be a viable method of disseminating evidence-based depression care.

Case Management↗
PubMed2005

Finding common ground: patient-centeredness and evidence-based chronic illness care.

Health outcomes for patients with major chronic illnesses depend on the appropriate use of proven pharmaceuticals and other therapeutic technologies, and effective self-management by patients. Effective chronic illness care then bases clinical decisions on the best, rigorous scientific evidence, or evidence-based medicine. Effective support for patient self-management includes efforts to increase patient participation in care and collaborative goal-setting and planning of treatment. These interventions appear somewhat consistent with recent conceptualizations of patient-centered care. The consistent delivery of proven therapies and information and support for self-management requires practice systems organized for that purpose. The Chronic Care Model is a compilation of those practice system changes shown to improve chronic care. This paper explores the concept of patient-centeredness and its relationship to the Chronic Care Model. We conclude that the Model is both evidence-based and patient-centered and that these can be properties of health systems, and not just of individual practitioners.

Chronic Disease↗
PubMed2005

Introduction.

Explore the source record for details and available documents.

Biomedical Research↗
PubMed2005

Building a research consortium of large health systems: the Cancer Research Network.

Critical questions about cancer prevention, care, and outcomes increasingly require research involving large patient populations and their care delivery organizations. The Cancer Research Network (CRN) includes 11 integrated health systems funded by the National Cancer Institute (NCI) to conduct collaborative cancer research. This article describes the challenges of constructing a productive consortium of large health systems, and explores the CRN's responses. The CRN was initially funded through an NCI cooperative agreement in 1999 and has since received a second 4-year grant. Leadership and policy development are provided through a steering committee, subcommittees, and an external advisory committee. The CRN includes integral and affiliated research projects supported by a Scientific and Data Resources Core. Three characteristics of the CRN intensified the general challenges of consortium research: 1) its members are large health systems with legitimate concerns about confidentiality of data about enrollees, providers, and the organization; 2) CRN research projects often generate highly sensitive data about quality of care; and therefore 3) each participating organization wants a strong voice in CRN direction. CRN experience to date confirms that a consortium of health systems with internal research capacity can address a range of important cancer research questions that would be difficult to study in other venues. The advantages and challenges of consortium research are explored, with suggestions for the development, execution, and management of multisystem population laboratories.

Biomedical Research↗
PubMed2005

Building a virtual cancer research organization.

BACKGROUND: The Cancer Research Network (CRN) comprises the National Cancer Institute and 11 nonprofit research centers affiliated with integrated health care delivery systems. The CRN, a public/private partnership, fosters multisite collaborative research on cancer prevention, screening, treatment, survival, and palliation in diverse populations. METHODS: The CRN's success hinges on producing innovative cancer research that likely would not have been developed by scientists working individually, and then translating those findings into clinical practice within multiple population laboratories. The CRN is a collaborative virtual research organization characterized by user-defined sharing among scientists and health care providers of data files as well as direct access to researchers, computers, software, data, research participants, and other resources. The CRN's research management Web site fosters a high-functioning virtual scientific community by publishing standardized data definitions, file specifications, and computer programs to support merging and analyzing data from multiple health care systems. RESULTS: Seven major types of standardized data files developed to date include demographics, health plan eligibility, tumor registry, inpatient and ambulatory utilization, medication dispensing, laboratory tests, and imaging procedures; more will follow. Data standardization avoids rework, increases multisite data integrity, increases data security, generates shorter times from initial proposal concept to submission, and stimulates more frequent collaborations among scientists across multiple institutions. CONCLUSIONS: The CRN research management Web site and associated standardized data files and procedures represent a quasi-public resource, and the CRN stands ready to collaborate with researchers from outside institutions in developing and conducting innovative public domain research.

Biomedical Research↗
PubMed2005

Measuring and improving performance in multicenter research consortia.

BACKGROUND: Some evidence suggests that the quality of the organization and management of research consortia influences productivity and staff satisfaction. Collaborators in a research consortium generally focus on developing and implementing studies and thus rarely assess the process of collaboration. We present an approach to evaluating and improving a research consortium, using the HMO Cancer Research Network (CRN) as an example. METHODS: Five domains are evaluated: extent of collaboration and quality of communication; performance of projects and infrastructure; data quality; scientific productivity; and impact on member organizations. The primary assessment tool is a survey of CRN scientists and project staff, undertaken annually. RESULTS: Each year, the evaluation has identified critical aspects of this collaboration that could be improved. Several tangible changes have been implemented to improve productivity of the consortium. The most important result of the CRN Evaluation is the ability to have open dialogue about ways to improve its overall performance. CONCLUSION: Optimizing the process of collaboration will contribute to achievement of the scientific goals. The experience of the CRN provides a useful framework and process for evaluating the structure of consortium-based research.

Biomedical Research↗
PubMed2005

Development and validation of the Patient Assessment of Chronic Illness Care (PACIC).

RATIONALE: There is a need for a brief, validated patient self-report instrument to assess the extent to which patients with chronic illness receive care that aligns with the Chronic Care Model-measuring care that is patient-centered, proactive, planned and includes collaborative goal setting; problem-solving and follow-up support. SAMPLE: A total of 283 adults reporting one or more chronic illness from a large integrated health care delivery system were studied. METHODS: Participants completed the 20-item Patient Assessment of Chronic Illness Care (PACIC) as well as measures of demographic factors, a patient activation scale, and subscales from a primary care assessment instrument so that we could evaluate measurement performance, construct, and concurrent validity of the PACIC. RESULTS: The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. As predicted, the PACIC was only slightly correlated with age and gender, and unrelated to education. Contrary to prediction, it was only slightly correlated (r = 0.13) with number of chronic conditions. The PACIC demonstrated moderate test-retest reliability (r = 0.58 during the course of 3 months) and was correlated moderately, as predicted (r = 0.32-0.60, median = 0.50, P < 0.001) to measures of primary care and patient activation. DISCUSSION: The PACIC appears to be a practical instrument that is reliable and has face, construct, and concurrent validity. The resulting questionnaire is in the public domain, and recommendations for its use in research and quality improvement are outlined.

Age Factors↗
PubMed2005

Practice-level effects of interventions to improve asthma care in primary care settings: the Pediatric Asthma Care Patient Outcomes Research Team.

OBJECTIVE: To assess the practice-level effects of (1) a physician peer leader intervention and (2) peer leaders in combination with the introduction of asthma education nurses to facilitate care improvement. And, to compare findings with previously reported patient-level outcomes of trial enrollees. STUDY SETTING: Data were included on children 5-17 years old with asthma in 40 primary care practices, affiliated with managed health care plans enrolled in the Pediatric Asthma Care Patient Outcomes Research Team (PORT) randomized trial. STUDY DESIGN: Primary care practices were randomly assigned to one of two care improvement arms or to usual care. Automated claims data were analyzed for 12-month periods using a repeated cross-sectional design. The primary outcome was evidence of at least one controller medication dispensed among patients with persistent asthma. Secondary outcomes included controller dispensing among all identified asthmatics, evidence of chronic controller use, and the dispensing of oral steroids. Health service utilization outcomes included numbers of ambulatory visits and hospital-based events. PRINCIPAL FINDINGS: The proportion of children with persistent asthma prescribed controllers increased in all study arms. No effect of the interventions on the proportion receiving controllers was detected (peer leader intervention effect 0.01, 95 percent confidence interval [CI]: -0.07, 0.08; planned care intervention effect -0.03, 95 percent CI: -0.09, 0.02). A statistical trend was seen toward an increased number of oral corticosteroid bursts dispensed in intervention practices. Significant adjusted increases in ambulatory visits of 0.08-0.10 visits per child per year were seen in the first intervention year, but only a statistical trend in these outcomes persisted into the second year of follow-up. No differences in hospital-based events were detected. CONCLUSIONS: This analysis showed a slight increase in ambulatory asthma visits as a result of asthma care improvement interventions, using automated data. The absence of detectable impact on medication use at the practice level differs from the positive intervention effect observed in patient self-reported data from trial enrollees. Analysis of automated data on nonenrollees adds information about practice-level impact of care improvement strategies. Benefits of practice-level interventions may accrue disproportionately to the subgroup of trial enrollees. The effect of such interventions may be less apparent at the level of practices or health plans.

Adolescent↗
PubMed2004

A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study.

BACKGROUND: Traditional primary care practice change approaches have not led to full implementation of national asthma guidelines. OBJECTIVE: To evaluate the effectiveness of 2 asthma care improvement strategies in primary care. DESIGN: Two-year randomized controlled clinical trial. SETTING: Forty-two primary care pediatric practices affiliated with 4 managed care organizations. PARTICIPANTS: Children aged 3 to 17 years with mild to moderate persistent asthma enrolled in primary care practices affiliated with managed care organizations. INTERVENTIONS: Peer leader education consisted of training 1 physician per practice in asthma guidelines and peer teaching methods. Planned care combined the peer leader program with nurse-mediated organizational change through planned visits with assessments, care planning, and self-management support, in collaboration with physicians. Analyses compared each intervention with usual care. MAIN OUTCOME MEASURES: Annualized asthma symptom days, asthma-specific functional health status (Children's Health Survey for Asthma), and frequency of brief oral steroid courses (bursts). RESULTS: Six hundred thirty-eight children completed baseline evaluations, representing 64% of those screened and eligible. Mean +/- SD age was 9.4 +/- 3.5 years; 60% were boys. Three hundred fifty (55%) were taking controller medication. Mean +/- SD annualized asthma symptom days was 107.4 +/- 122 days. Children in the peer leader arm had 6.5 fewer symptom days per year (95% confidence interval [CI], - 16.9 to 3.6), a nonsignificant difference, but had a 36% (95% CI, 11% to 54%) lower oral steroid burst rate per year compared with children receiving usual care. Children in the planned care arm had 13.3 (95% CI, - 24.7 to -2.1) fewer symptom days annually (-12% from baseline; P =.02) and a 39% (95% CI, 11% to 58%) lower oral steroid burst rate per year relative to usual care. Both interventions showed small, statistically significant effects for 2 of 5 Children's Health Survey for Asthma scales. Planned care subjects had greater controller adherence (parent report) compared with usual care subjects (rate ratio, 1.05 [95% CI, 1.00 to 1.09]). CONCLUSIONS: Planned care (nurse-mediated organizational change plus peer leader education) is an effective model for improving asthma care in the primary care setting. Peer leader education on its own may also serve as a useful model for improving asthma care, although it is less comprehensive and the treatment effect less pronounced.

Administration, Oral↗
PubMed2004

Clinical and sociodemographic factors associated with colon surveillance among patients with a history of colorectal cancer.

BACKGROUND: Substantial variability in the use of colon surveillance among colorectal cancer survivors has been reported. This study sought to examine trends in the use of colon surveillance among patients who have had colorectal cancer and to investigate factors associated with utilization. METHODS: Health maintenance organization enrollees with a diagnosis of local or regional colon or rectal cancer between January 1993 and December 1999 were studied. Receipt of a colon examination by colonoscopy or by flexible sigmoidoscopy, together with barium contrast radiography of the colon was determined from automated clinical records, and rates of colon surveillance were estimated by using survival analysis. RESULTS: A total of 1002 patients with a diagnosis of colorectal cancer met inclusion criteria for the study. Colon examinations were performed in 61% of patients within 18 months of diagnosis and in 80% of patients within 5 years of diagnosis. The median time from diagnosis to first colon surveillance examination (14 months) was unchanged over the study period, but the interval between first and second surveillance examinations increased by 17 months (p<0.001). Patients over 80 years of age (relative risk=0.32; 95% CI[0.22, 0.45]) and those with rectal cancer (relative risk=0.80; 95% CI[0.66, 0.97]) were less likely to undergo surveillance. Higher socioeconomic status (relative risk=1.29; 95% CI[1.03, 1.61]) and being married (relative risk=1.27; 95% CI[1.05, 1.53]) were associated with greater utilization. There was lower utilization among African American patients (relative risk=0.70; p=0.14) and increased utilization among other minorities (relative risk=1.47; p=0.06). CONCLUSIONS: There is substantial variability in the use of colon examination for surveillance in patients with a history of colorectal cancer, and clinical and sociodemographic factors appear to influence the likelihood of surveillance.

Age Factors↗
PubMed2004

A state-level application of the chronic illness breakthrough series: results from two collaboratives on diabetes in Washington State.

BACKGROUND: Breakthrough Series Collaboratives addressing chronic conditions have been conducted at the national level and in single health care delivery systems but not at the state level. Two state-level collaboratives were conducted: Diabetes Collaborative I (October 1999-November 2000) included 17 clinic teams from across the state, and Diabetes Collaborative II (February 2001-March 2002) included 30 teams and 6 health plans. METHODS: Both collaboratives took place in Washington State, where a diverse group of primary care practices participated, and health insurance plans partnered with the clinic teams. Teams individually tested and implement changes in their systems of care to address all components of the Chronic Care Model. RESULTS: All 47 teams completed the collaboratives, and all but one maintained a registry throughout the 13 months. Most teams demonstrated some amount of improvement on process and outcome measures that addressed blood sugar testing and control, blood pressure control, lipid testing and control, foot exams, dilated eye exams, and self-management goals. CONCLUSION: The benefits of holding collaboratives more locally include increased technical support and increased participation, translating into wider implementation of prevention-focused, patient-centered care.

Chronic Disease↗