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PURPOSE Research on primary care's role in a pandemic response has not adequately considered the day-to-day needs of clinicians in the midst of a crisis. We created an Oregon COVID-19 ECHO (Extension for Community Healthcare Outcomes) program, a telementoring education model for clinicians. The program was adapted for a large audience and encouraged interactivity among the hundreds of participants via the chat box. We assessed how chat box communications within the statewide program identified and ameliorated some of clinicians' needs during the pandemic. METHODS We conducted a qualitative analysis of chat box transcripts from 11 sessions. We coded transcripts using the editing method, whereby analysts generate categories predominantly from the data, but also from prior knowledge. We then explored the context of clinicians' needs in a pandemic, as conceptualized in Maslow's hierarchy of needs adapted for physicians: physiologic, safety, love and belonging, esteem, and self-actualization. RESULTS The mean number of chat box participants was 492 per session (range, 385 to 753). Participants asked 1,452 questions and made 819 comments throughout the program. We identified 3 key themes: seeking answers and trustworthy information, seeking practical resources, and seeking and providing affirmation and peer support. These themes mapped onto the Maslow's needs framework. We found that participants were able to create a virtual community in the chat box that supported many of their needs. CONCLUSIONS Using a novel data source, we found sharing the experience of practicing in a rapidly changing environment via comments and questions in an ECHO program both defined and supported participants' needs. Key words: COVID-19; primary health care; clinician well-being; project ECHO; professional practice; support groups; communication; health informatics; continuing medical education, INTRODUCTION As COVID-19 moved across the United States in early 2020, primary care clinicians faced dramatic changes to their practices, often with little assistance and inconsistent guidance. (1) Without a [...]

Background: Unhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care. Methods: ANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center—state leaders in Medicaid health system transformation—SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework. Discussion: This study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics. [ABSTRACT FROM AUTHOR]

Abstract Background Physicians are being asked to report errors from primary care, but little is known about how they apply the term "error." This study qualitatively assesses the relationship between the variety of error definitions found in the medical literature and physicians' assessments of whether an error occurred in a series of clinical scenarios. Methods A systematic literature review and pilot survey results were analyzed qualitatively to search for insights into what may affect the use of the term error. The National Library of Medicine was systematically searched for medical error definitions. Survey participants were a random sample of active members of the American Academy of Family Physicians (AAFP) and a selected sample of family physician patient safety "experts." A survey consisting of 5 clinical scenarios with problems (wrong test performed, abnormal result not followed-up, abnormal result overlooked, blood tube broken and missing scan results) was sent by mail to AAFP members and by e-mail to the experts. Physicians were asked to judge if an error occurred. A qualitative analysis was performed via "immersion and crystallization" of emergent insights from the collected data. Results While one definition, that originated by James Reason, predominated the literature search, we found 25 different definitions for error in the medical literature. Surveys were returned by 28.5% of 1000 AAFP members and 92% of 25 experts. Of the 5 scenarios, 100% felt overlooking an abnormal result was an error. For other scenarios there was less agreement (experts and AAFP members, respectively agreeing an error occurred): 100 and 87% when the wrong test was performed, 96 and 87% when an abnormal test was not followed up, 74 and 62% when scan results were not available during a patient visit, and 57 and 47% when a blood tube was broken. Through qualitative analysis, we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility Conclusion There is a lack of consensus about what constitutes an error both in the medical literature and in decision making by family physicians. These potential areas of confusion need further study.

The article presents a commentary on rapid deployment of a statewide COVID-19 Extension for Community Healthcare Outcomes (ECHO) Program for frontline clinicians. Topics include urgent need for the rapid dissemination of emerging public health and treatment best practices, scientific evidence, and available resources for rural clinicians; and ideal model for the rapid dissemination of pertinent information to rural clinicians during a crisis.

The ways homelessness and diabetes affect each other is not well known. The authors sought to understand barriers and enablers to health for homeless people with diabetes as perceived by homeless persons and providers. The authors performed semistructured interviews with a sample of participants (seven homeless persons, six social service providers, and five medical providers) in an urban Midwest community. Data analysis was performed with the qualitative editing method. Participants described external factors (chaotic lifestyle, diet/food availability, access to care, and medications) and internal factors (competing demands, substance abuse, stress) that directly affect health. Social service providers were seen as peripheral to diabetes care, although all saw their primary functions as valuable. These factors and relationships are appropriately modeled in a complex adaptive chronic care model, where the framework is bottom up and stresses adaptability, self-organization, and empowerment. Adapting the care of homeless persons with diabetes to include involvement of patients and medical and social service providers must be emergent and responsive to changing needs. [ABSTRACT FROM PUBLISHER]

Background: Hospice provides a full range of services for patients near the end of life, often in the patient's own home. There are no published studies that describe patient safety incidents in home hospice care. Objective: The study objective was to explore the types and characteristics of patient safety incidents in home hospice care from the experiences of hospice interdisciplinary team members. Methods: The study design is qualitative and descriptive. From a convenience sample of 17 hospices in 13 states we identified 62 participants including hospice nurses, physicians, social workers, chaplains, and home health aides. We interviewed a separate sample of 19 experienced hospice leaders to assess the credibility of primary results. Semistructured telephone interviews were recorded and transcribed. Four researchers used an editing technique to identify common themes from the interviews. Results: Major themes suggested a definition of patient safety in home hospice that includes concern for unnecessary harm to family caregivers or unnecessary disruption of the natural dying process. The most commonly described categories of patient harm were injuries from falls and inadequate control of symptoms. The most commonly cited contributing factors were related to patients, family caregivers, or the home setting. Few participants recalled incidents or harm related to medical errors by hospice team members. Conclusions: This is the first study to describe patient safety incidents from the experiences of hospice interdisciplinary team members. Compared with patient safety studies from other health care settings, participants recalled few incidents related to errors in evaluation, treatment, or communication by the hospice team. [ABSTRACT FROM AUTHOR]

PURPOSE The clinician-colleague relationship is a cornerstone of relationship-centered care (RCC); in small family medicine offices, the clinician-medical assistant (MA) relationship is especially important. We sought to better understand the relationship between MA roles and the clinician-MA relationship within the RCC framework. METHODS We conducted an ethnographic study of 5 small family medicine offices (having <5 clinicians) in the Cincinnati Area Research and Improvement Group (CARInG) Network using interviews, surveys, and observations. We interviewed 19 MAs and supervisors and 11 clinicians (9 family physicians and 2 nurse practitioners) and observed 15 MAs in practice. Qualitative analysis used the editing style. RESULTS MAs' roles in small family medicine offices were determined by MA career motivations and clinician-MA relationships. MA career motivations comprised interest in health care, easy training/workload, and customer service orientation. Clinician-MA relationships were influenced by how MAs and clinicians respond to their perceptions of MA clinical competence (illustrated predominantly by comparing MAs with nurses) and organizational structure. We propose a model, trust and verify, to describe the structure of the clinician-MA relationship. This model is informed by clinicians' roles in hiring and managing MAs and the social familiarity of MAs and clinicians. Within the RCC framework, these findings can be seen as previously undefined constraints and freedoms in what is known as the Complex Responsive Process of Relating between clinicians and MAs. CONCLUSIONS Improved understanding of clinician-MA relationships will allow a better appreciation of how clinicians and MAs function in family medicine teams. Our findings may assist small offices undergoing practice transformation and guide future research to improve the education, training, and use of MAs in the family medicine setting. [ABSTRACT FROM AUTHOR]

The article presents a survey that explores management of test results in family medicine offices. The survey shows that no office systematically cohered to office-wide results management practices and just two offices had written protocols for results management steps. It reveals that 87-100% of patients recognized getting their test results and 58-85% of patients charts supported patient notification.

Abstract: Objective: To develop a survey to measure seniors’ embracement of ambulatory patient safety self-advocacy behaviors, the Senior Empowerment and Advocacy in Patient Safety (SEAPS) survey. Methods: Content was developed by review of published recommendations combined with interviews and focus groups with community members; items were generated for subscales based on the health belief model (HBM). Psychometric characteristics were assessed by cluster and correlation analyses on a pilot test of 143 community dwelling seniors; the ability of the subscales and demographic variables to predict reported behavior was investigated by multiple regression. Results: The four subscales of the SEAPS were outcome efficacy (OE), attitudes (ATT), self-efficacy (SE) and behaviors (BEH). Cronbach alphas were 0.74 for ATT, 0.79 for BEH, and 0.91 for OE and SE. Analysis of variance showed that there were no differences in any subscale score by race, education level or frequency of doctor visits, but women were noted to have significantly higher scores (p <.01) on the ATT and SE subscales and for the total of all the scales. Multiple regressions showed that SE significantly predicted self-reported behavior (p <.001). OE was a significant predictor for whites (p <.001) but not for African-Americans (p =.24). Conclusions: We have developed a short, 21-item self-administered survey to assess seniors’ views about their participation in safety tasks. Practice implications: We believe the SEAPS shows promise to be a tool for evaluating interventions and training programs aimed at improving seniors’ self-advocacy skills. Effective interventions may improve the involvement of patients in their own safety in the clinical setting. [Copyright &y& Elsevier]

Background: Physicians are being asked to report errors from primary care, but little is known about how they apply the term "error." This study qualitatively assesses the relationship between the variety of error definitions found in the medical literature and physicians' assessments of whether an error occurred in a series of clinical scenarios. Methods: A systematic literature review and pilot survey results were analyzed qualitatively to search for insights into what may affect the use of the term error. The National Library of Medicine was systematically searched for medical error definitions. Survey participants were a random sample of active members of the American Academy of Family Physicians (AAFP) and a selected sample of family physician patient safety "experts." A survey consisting of 5 clinical scenarios with problems (wrong test performed, abnormal result not followed-up, abnormal result overlooked, blood tube broken and missing scan results) was sent by mail to AAFP members and by e-mail to the experts. Physicians were asked to judge if an error occurred. A qualitative analysis was performed via "immersion and crystallization" of emergent insights from the collected data. Results: While one definition, that originated by James Reason, predominated the literature search, we found 25 different definitions for error in the medical literature. Surveys were returned by 28.5% of 1000 AAFP members and 92% of 25 experts. Of the 5 scenarios, 100% felt overlooking an abnormal result was an error. For other scenarios there was less agreement (experts and AAFP members, respectively agreeing an error occurred): 100 and 87% when the wrong test was performed, 96 and 87% when an abnormal test was not followed up, 74 and 62% when scan results were not available during a patient visit, and 57 and 47% when a blood tube was broken. Through qualitative analysis, we found that three areas may affect how physicians make decisions about error: the process that occurred vs. the outcome that occurred, rare vs. common occurrences and system vs. individual responsibility Conclusion: There is a lack of consensus about what constitutes an error both in the medical literature and in decision making by family physicians. These potential areas of confusion need further study. [ABSTRACT FROM AUTHOR]

Objective: To describe and classify process errors and preventable adverse events that occur from medical care in outpatient primary care settings.Study Design: Systematic review and synthesis of the medical literature.Data Sources: We searched MEDLINE and the Cochrane Library from 1965 through March 2001 with the MESH term medical errors, modified by adding family practice, primary health care, physicians/family, or ambulatory care and limited the search to English-language publications. Published bibliographies and Web sites from patient safety and primary care organizations were also reviewed for unpublished reports, presentations, and leads to other sites, journals, or investigators with relevant work. Additional papers were identified from the references of the papers reviewed and from seminal papers in the field.Outcomes Measured: Process errors and preventable adverse events.Results: Four original research studies directly studied and described medical errors and adverse events in primary care, and 3 other studies peripherally addressed primary care medical errors. A variety of quantitative and qualitative methods were used in the studies. Extraction of results from the studies led to a classification of 3 main categories of preventable adverse events: diagnosis, treatment, and preventive services. Process errors were classified into 4 categories: clinician, communication, administration, and blunt end.Conclusions: Original research on medical errors in the primary care setting consists of a limited number of small studies that offer a rich description of medical errors and preventable adverse events primarily from the physician's viewpoint. We describe a classification derived from these studies that is based on the actual practice of primary care and provides a starting point for future epidemiologic and interventional research. Missing are studies that have patient, consumer, or other health care provider input. [ABSTRACT FROM AUTHOR]

Qualitative research is now published across the family practice and medical literature. This article is designed to help busy family physicians decide which qualitative studies are worth reading and to provide them with the tools to appreciate and evaluate research design and analysis. By using clinical analogies, the qualitative research process can be better understood. [ABSTRACT FROM AUTHOR]

The article focuses on the efficiency of interprofessional collaborative care (ICC) in enhancing management of chronic pain patients. Topics discussed include the study being done through semistructured interviews with with various pain providers in an urban area in midwestern U.S. like primary care physicians (PCPs), pain management doctors and integrative medicine doctors, results showing most professionals wanted PCPs to be the center of ICC and ways to enhance ICC.

Background. Competent physicians occasionally make critical errors in patient care that can lead to long-lasting remorse and guilt. The perceived causes of self-admitted physician errors have not been previously explored. Methods. Fifty-three family physicians were interviewed in depth and asked to describe their most memorable errors and the perceived causes. The authors analyzed transcripts of the audiotaped interviews to determine the frequencies of the different causes. Errors were classified according to four general categories. Results. Family physicians collectively reported a mean of 8 different causes for each case in which an error was made (range, 1 to 16). In 47% of the cases, the patient died following the error, whereas in 26% of the cases, there was no adverse outcome. Only 4 of the 53 errors led to malpractice suits, and none were addressed by peer review organizations. Seven (10%) of the 70 physicians who were invited to participate could not recall having made any errors. Family physicians attributed their most memorable errors to 34 different causes, which fit into the following categories: physician stressors (eg, being hurried or distracted), process-of-care factors (eg, premature closure of the diagnostic process), patient-related factors (eg, misleading normal findings), and physician characteristics (eg, lack of knowledge). Conclusions. Family physicians attribute their memorable errors to a wide variety of causes, but most commonly to hurry, distraction, lack of knowledge, premature closure of the diagnostic process, and inadequately aggressive patient management. Physicians who understand common causes of errors may be better prepared to prevent them. [ABSTRACT FROM AUTHOR]