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Objectives: The objectives of this study were to: (1) understand the personal impact of workplace violence (WPV) on staff within a large multistate emergency medical services (EMS) agency, (2) describe the impact of WPV on subsequent patient interactions, examining how experiences of violence affect the quality of care provided by EMS clinicians, (3) examine the influence of WPV on perceived workplace safety among prehospital personnel and its correlation with retention in the EMS field, and (4) solicit recommendations from staff for the prevention and mitigation of WPV in the future., Methods: We conducted virtual focus groups and individual interviews with 22 prehospital personnel using a descriptive qualitative design within a large multistate Midwest EMS agency between 4/5/2023-6/20/2023. Data were analyzed using Thematic Analysis to identify common perceptions among and across participants., Results: Major themes of personal impact; impact on patient interactions; influence of WPV on career longevity/sustainability; and relationship between EMS culture and WPV were identified. Overall, participants shared the perception that WPV is "part of the job", and that verbal abuse was so common that they hadn't previously considered it as violence. Participants provided several examples of WPV and described how these experiences impacted them personally (e.g., hypervigilance) and impacted their subsequent interaction with patients (e.g., quicker to use restraints, loss of empathy). Participants shared the perception that EMS is no longer valued or respected by patients or communities. Several voiced concerns for the next generation of colleagues and nearly all participants reported the need for education and training in situational awareness, de-escalation, and self-defense tactics. Participants referenced desire for more coordination and communication with law enforcement, change in culture of abuse from patients without repercussions, and improved agency mental health support and peer support/mentoring following a violent event. Despite experiences with WPV, the majority reported plans to remain in EMS., Conclusions: Emergency Medical Services personnel are commonly traumatized by violence in their work and nonphysical violence is underappreciated. Despite its impact on staff and subsequent patient interactions, most participants reported plans to remain within EMS. Multi-faceted system-focused efforts are needed to shift toward and support a zero-tolerance culture for WPV.

The Adult Medical Care Coordination program ("the program") was implemented at Mayo Clinic to promote patient self-management and improve 30-day unplanned readmission for patients with high risk for readmission after hospital discharge. This study aimed to evaluate the impact of the program compared to usual care using a pragmatic, stepped wedge cluster randomized trial ("stepped wedge trial"). However, several challenges arose including large differences between the study arms. Our goal is to describe the challenges and present lessons learned on how to overcome such challenges and generate evidence to support practice decisions. We describe the challenges encountered during the trial, the approach to addressing these challenges, and lessons learned for other learning health system researchers facing similar challenges. The trial experienced several challenges in implementation including several clinics dropping from the study and care disruptions due to COVID-19. Additionally, there were large differences in the patient population between the program and usual care arms. For example, the mean age was 76.8 for the program and 68.1 for usual care. Due to these differences, we adapted the methods using the propensity score matching approach that is traditionally applied to observational designs and adjusted for differences in observable characteristics. When conducting pragmatic research, researchers will encounter factors beyond their control that may introduce bias. The lessons learned include the need to weigh the tradeoffs of pragmatic design elements and the potential value of adaptive designs for pragmatic trials. Applying these lessons would promote the successful generation of evidence that informs practice decisions., Competing Interests: Dr. Borah has received consulting fees from Exact Sciences and Boehringer Ingelheim for work not related to this manuscript. The other authors have no conflicts to report., (© 2024 The Authors. Learning Health Systems published by Wiley Periodicals LLC on behalf of the University of Michigan.)

Objective: To evaluate the impact of a virtual registered nurse (ViRN) model on safety and care outcomes. ViRN is a telemedicine intervention that enables an experienced virtual nurse to assist the in-person care team in providing care to patients., Data Sources and Study Setting: Electronic health records data were utilized from the Mayo Clinic during the intervention (December 2020-November 2021) and historical periods (December 2018-November 2019). ViRN was implemented on general medical units at the Mayo Clinic Rochester. We used general medical units at the Mayo Clinic Arizona as the comparison group., Study Design: This study used a difference-in-differences design to evaluate the impact of ViRN compared to usual care on transfer to the intensive care unit (ICU), inpatient mortality, and length of stay (LOS). We used logistic regression for transfer to the ICU and inpatient mortality and negative binomial regression for LOS. We controlled for demographics, patient interaction with the health system, clinical characteristics, and admission characteristics. We clustered standard errors to account for patients who have multiple admissions during the study period., Principal Findings: There were no significant differences for transfer to the ICU (average marginal effect (AME) -0.08 percentage point [95% confidence interval (CI): -1.34, 1.18]), inpatient mortality (AME 0.43 percentage point [95% CI: -0.33, 1.18]), or LOS (AME -0.20 days [95% CI: -0.57, 0.17]). The findings were mostly consistent across the sensitivity analyses., Conclusions: Our results suggest that ViRN led to similar outcomes as usual care in general medical units. These findings support the potential to develop more advanced models of ViRN at the Mayo Clinic and the dissemination of the ViRN model to other systems. In the context of staffing shortages and other disruptions to the delivery of nursing care, it is critical to understand whether new models like ViRN provide nurse staffing alternatives without negatively affecting outcomes., (© 2023 Health Research and Educational Trust.)

Background and Objectives: Continuity of care is an integral aspect of high-quality patient care in primary care settings. In the Department of Family Medicine at Mayo Clinic, providers have multiple responsibilities in addition to clinical duties or panel management time (PMT). These competing time demands limit providers' clinical availability. One way to mitigate the impact on patient access and care continuity is to create provider care teams to collectively share the responsibility of meeting patients' needs., Methods: This study presents a descriptive characterization of patient care continuity based on provider types and PMT. Care continuity was measured by the percentage of patient a ppointments s een by a provider in their o wn c are t eam (ASOCT) with the aim of reducing the variability of provider care team continuity. The prediction method is iteratively developed to illustrate the importance of the individual independent components. An optimization model is then used to determine optimal provider mix in a team., Results: The ASOCT percentage in current practice among care teams ranges from 46% to 68% and the per team number of MDs varies from 1 to 5 while the number of nurse practitioners and physician assistants (NP/PAs) ranges from 0 to 6. The proposed methods result in the optimal provider assignment, which has an ASOCT percentage consistently at 62% for all care teams and 3 or 4 physicians (MDs) and NP/PAs in each care team., Conclusions: The predictive model combined with assignment optimization generates a more consistent ASOCT percentage, provider mix, and provider count for each care team., Competing Interests: The authors declare no conflicts of interest, (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We sought to ascertain factors associated with the quality of diabetes care, comparing rural vs urban diabetic patients in a large health care system., Methods: We conducted a retrospective cohort study assessing patients' attainment of the D5 metric, a diabetes care metric having 5 components (no tobacco use, glycated hemoglobin [A 1c ] level less than 8%, blood pressure less than 140/90 mm Hg, low-density lipoprotein cholesterol level at goal or statin prescribed, and aspirin use consistent with clinical recommendations). Covariates included age, sex, race, adjusted clinical group (ACG) score as a marker of complexity, insurance type, primary care clinician type, and health care use data., Results: The study cohort consisted of 45,279 patients with diabetes, 54.4% of whom resided in rural locations. The D5 composite metric was met in 39.9% of rural patients and 43.2% of urban patients ( P <.001). Rural patients were significantly less likely to have attained all metric goals than urban counterparts (adjusted odds ratio [AOR] = 0.93; 95% CI, 0.88-0.97). The rural group had fewer outpatient visits (mean number of visits = 3.2 vs 3.9, P <.001) and less often had an endocrinology visit (5.5% vs 9.3%, P <.001) during the 1-year study period. Patients with an endocrinology visit were less likely to have met the D5 metric (AOR = 0.80; 95% CI, 0.73-0.86), whereas the more outpatient visits patients had, the greater their likelihood of attainment (AOR per visit = 1.03; 95% CI, 1.03-1.04)., Conclusions: Rural patients had worse diabetes quality outcomes than their urban counterparts, even after adjustment for other contributing factors and despite being part of the same integrated health system. Lower visit frequency and less specialty involvement in the rural setting are possible contributing factors., (© 2023 Annals of Family Medicine, Inc.)

Background: New patient-centered models of care are needed to individualize care and reduce high-cost care, including emergency department (ED) visits and hospitalizations for low- and intermediate-acuity conditions that could be managed outside the hospital setting. Community paramedics (CPs) have advanced training in low- and high-acuity care and are equipped to manage a wide range of health conditions, deliver patient education, and address social determinants of health in the home setting. The objective of this trial is to evaluate the effectiveness and implementation of the Care Anywhere with Community Paramedics (CACP) program with respect to shortening and preventing acute care utilization., Methods: This is a pragmatic, hybrid type 1, two-group, parallel-arm, 1:1 randomized clinical trial of CACP versus usual care that includes formative evaluation methods and assessment of implementation outcomes. It is being conducted in two sites in the US Midwest, which include small metropolitan areas and rural areas. Eligible patients are ≥ 18 years old; referred from an outpatient, ED, or hospital setting; clinically appropriate for ambulatory care with CP support; and residing within CP service areas of the referral sites. Aim 1 uses formative data collection with key clinical stakeholders and rapid qualitative analysis to identify potential facilitators/barriers to implementation and refine workflows in the 3-month period before trial enrollment commences (i.e., pre-implementation). Aim 2 uses mixed methods to evaluate CACP effectiveness, compared to usual care, by the number of days spent alive outside of the ED or hospital during the first 30 days following randomization (primary outcome), as well as self-reported quality of life and treatment burden, emergency medical services use, ED visits, hospitalizations, skilled nursing facility utilization, and adverse events (secondary outcomes). Implementation outcomes will be measured using the RE-AIM framework and include an assessment of perceived sustainability and metrics on equity in implementation. Aim 3 uses qualitative methods to understand patient, CP, and health care team perceptions of the intervention and recommendations for further refinement. In an effort to conduct a rigorous evaluation but also speed translation to practice, the planned duration of the trial is 15 months from the study launch to the end of enrollment., Discussion: This study will provide robust and timely evidence for the effectiveness of the CACP program, which may pave the way for large-scale implementation. Implementation outcomes will inform any needed refinements and best practices for scale-up and sustainability., Trial Registration: ClinicalTrials.gov NCT05232799. Registered on 10 February 2022., (© 2023. The Author(s).)

Pragmatic trials aim to generate timely evidence while ensuring feasibility, minimizing practice burden, and maintaining real-world conditions. We conducted rapid-cycle qualitative research in the preimplementation period of a trial evaluating a community paramedic program to shorten and prevent hospitalizations. Between December 2021 and March 2022, interviews ( n = 30) and presentations/discussions ( n = 17) were conducted with clinical and administrative stakeholders. Two investigators analyzed interview and presentation data to identify potential trial challenges, and team reflections were used to develop responsive strategies. Solutions were implemented prior to the commencement of trial enrollment and were aimed at bolstering feasibility and building ongoing practice feedback loops., Competing Interests: In the last 36 months, Dr McCoy has received support from NIDDK, PCORI, and AARP®. She also serves as a consultant to Emmi® (Wolters Kluwer) on developing patient education materials related to prediabetes and diabetes. All other authors declare no conflicts., (© The Author(s) 2023.)

Objective: The aim of this study was to analyze the perceptions of core team members implementing patient-centered medical home (PCMH) within the Veterans Health Administration regarding delegation of work., Background: Significant overlap exists in the performance of work tasks among PCMH team members (primary care providers, RNs, clinical associates, clerks), and scant literature exists on appropriate delegation within PCMH teams., Methods: This study conducted used a quantitative and qualitative analysis of 4254 respondents to a 2018 survey., Results: Primary care providers rely heavily on team members, and nurses report being relied upon at high levels. Lack of role clarity and a perceived need for a team leader were concerns voiced by participants., Conclusions: Findings indicated a need for clear guidance on roles and responsibilities within the team. Patient-centered medical home team members need information about the scope of practice of each professional group to allow providers to function at the top of their scope of practice and ensure effective delegation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Delivering acute hospital care to patients at home might reduce costs and improve patient experience. Mayo Clinic's Advanced Care at Home (ACH) program is a novel virtual hybrid model of "Hospital at Home." This pragmatic randomized controlled non-inferiority trial aims to compare two acute care delivery models: ACH vs. traditional brick-and-mortar hospital care in acutely ill patients., Methods: We aim to enroll 360 acutely ill adult patients (≥18 years) who are admitted to three hospitals in Arizona, Florida, and Wisconsin, two of which are academic medical centers and one is a community-based practice. The eligibility criteria will follow what is used in routine practice determined by local clinical teams, including clinical stability, social stability, health insurance plans, and zip codes. Patients will be randomized 1:1 to ACH or traditional inpatient care, stratified by site. The primary outcome is a composite outcome of all-cause mortality and 30-day readmission. Secondary outcomes include individual outcomes in the composite endpoint, fall with injury, medication errors, emergency room visit, transfer to intensive care unit (ICU), cost, the number of days alive out of hospital, and patient-reported quality of life. A mixed-methods study will be conducted with patients, clinicians, and other staff to investigate their experience., Discussion: The pragmatic trial will examine a novel virtual hybrid model for delivering high-acuity medical care at home. The findings will inform patient selection and future large-scale implementation., Trial Registration: ClinicalTrials.gov NCT05212077. Registered on 27 January 2022., (© 2022. The Author(s).)

Introduction: Diabetes is one of the most common serious chronic health conditions in the USA. People living with diabetes face multiple barriers to optimal diabetes care, including gaps in access to medical care and self-management education, diabetes distress, and high burden of treatment. Community paramedics (CPs) are uniquely positioned to support multidisciplinary care for patients with diabetes by delivering focused diabetes self-management education and support and bridging the gaps between patients and the clinical and community resources they need to live well with their disease., Methods and Analysis: We will conduct a pragmatic single-arm prospective trial of a CP-led Diabetes Rescue, Engagement and Management (D-REM) programme that seeks to reduce diabetes distress. We will enrol 70 adults (≥18 years) with diabetes who have haemoglobin A1c (HbA1c)≥9.0%, experienced an emergency department (ED) visit or hospitalisation for any cause within the prior 6 months, and reside in areas with available CP support in Southeast Minnesota (Olmsted, Freeborn and Mower counties) and Northwest Wisconsin (Barron, Rusk and Dunn counties). Participants will be identified using Mayo Clinic electronic health records, contacted for consent and enrolled into the D-REM programme. Visit frequency will be individualised for each patient, but will be an average of four CP visits over the course of approximately 1 month. Outcomes will be change in diabetes distress (primary outcome), confidence in diabetes self-management, health-related quality of life, self-reported hypoglycaemia and hyperglycaemia, HbA1c, ED visits and hospitalisations. Outcomes will be assessed on enrolment, programme completion and 3 months after programme completion., Ethics and Dissemination: The study was approved by Mayo Clinic Institutional Review Board. Findings will be disseminated through peer-reviewed publications and presentations. If demonstrated to be successful, this model of care can be implemented across diverse settings and populations to support patients living with diabetes., Trial Registration Number: NCT04385758., Competing Interests: Competing interests: In the last 36 months, RGM received support from NIDDK, PCORI and AARP. She also serves as a consultant to Emmi (Wolters Kluwer) on developing patient education materials related to diabetes., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Diabetes management operates under a complex interrelationship between behavioral, social, and economic factors that affect a patient's ability to self-manage and access care., Objective: To examine the association between 2 complementary area-based metrics, area deprivation index (ADI) score and rurality, and optimal diabetes care., Design, Setting, and Participants: This cross-sectional study analyzed the electronic health records of patients who were receiving care at any of the 75 Mayo Clinic or Mayo Clinic Health System primary care practices in Minnesota, Iowa, and Wisconsin in 2019. Participants were adults with diabetes aged 18 to 75 years. All data were abstracted and analyzed between June 1 and November 30, 2020., Main Outcomes and Measures: The primary outcome was the attainment of all 5 components of the D5 metric of optimal diabetes care: glycemic control (hemoglobin A1c <8.0%), blood pressure (BP) control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg), lipid control (use of statin therapy according to recommended guidelines), aspirin use (for patients with ischemic vascular disease), and no tobacco use. The proportion of patients receiving optimal diabetes care was calculated as a function of block group-level ADI score (a composite measure of 17 US Census indicators) and zip code-level rurality (calculated using Rural-Urban Commuting Area codes). Odds of achieving the D5 metric and its components were assessed using logistic regression that was adjusted for demographic characteristics, coronary artery disease history, and primary care team specialty., Results: Among the 31 934 patients included in the study (mean [SD] age, 59 [11.7] years; 17 645 men [55.3%]), 13 138 (41.1%) achieved the D5 metric of optimal diabetes care. Overall, 4090 patients (12.8%) resided in the least deprived quintile (quintile 1) of block groups and 1614 (5.1%) lived in the most deprived quintile (quintile 5), while 9193 patients (28.8%) lived in rural areas and 2299 (7.2%) in highly rural areas. The odds of meeting the D5 metric were lower for individuals residing in quintile 5 vs quintile 1 block groups (odds ratio [OR], 0.72; 95% CI, 0.67-0.78). Patients residing in rural (OR, 0.84; 95% CI, 0.73-0.97) and highly rural (OR, 0.81; 95% CI, 0.72-0.91) zip codes were also less likely to attain the D5 metric compared with those in urban areas., Conclusions and Relevance: This cross-sectional study found that patients living in more deprived and rural areas were significantly less likely to attain high-quality diabetes care compared with those living in less deprived and urban areas. The results call for geographically targeted population health management efforts by health systems, public health agencies, and payers.

Background: Leaders play a crucial role in implementing and sustaining changes in clinical practice, yet there is limited evidence on the strategies to engage them in team problem solving and communication., Objective: Examine the impact of an intervention focused on facilitating leadership during daily huddles on optimizing team-based care and improving outcomes., Design: Cluster-randomized trial using intention-to-treat analysis to measure the effects of the intervention (n = 13 teams) compared with routine practice (n = 16 teams)., Participants: Twenty-nine primary care clinics affiliated with a large integrated health system in the upper Midwest; representing differing practice types and geographic settings., Intervention: Full-day leadership training retreat for team leaders to facilitate of care team huddles. Biweekly coaching calls and two site visits with an assigned coach., Main Measures: Primary outcomes of team development and function were collected, pre- and post-intervention using surveys. Patient satisfaction and quality outcomes were compared pre- and post-intervention as secondary outcomes. Leadership engagement and adherence to the intervention were also assessed., Key Results: A total of 279 pre-intervention and 272 post-intervention surveys were completed. We found no impact on team development (- 0.98, 95% CI (- 3.18, 1.22)), improved team credibility (0.18, 95% CI (0.00, 0.35)), but worse psychological safety (- 0.19, 95% CI (- 0.38, 0.00)). No differences were observed in patient satisfaction; however, results were mixed among quality outcomes. Post hoc analysis within the intervention group showed higher adherence to the intervention was associated with improvement in team coordination (0.47, 95% CI (0.18, 0.76)), credibility (0.28, 95% CI (0.02, 0.53)), team learning (0.42, 95% CI (0.10, 0.74)), and knowledge creation (0.74, 95% CI (0.35, 1.13)) compared to teams that were less engaged., Conclusions: Results of this evaluation showed that leadership training and facilitation were not associated with better team functioning. Additional components to the intervention tested may be necessary to enhance team functioning., Trial Registration: Clinicaltrials.gov Identifier NCT03062670. Registration Date: February 23, 2017. URL: https://clinicaltrials.gov/ct2/show/NCT03062670., (© 2021. Society of General Internal Medicine.)

The objective was to determine if a greater proportion of physician full-time equivalent (FTE%) relative to nurse practitioners/physician assistants (NPs/PAs) on care teams was associated with improved individual clinician diabetes quality outcomes. The authors conducted a retrospective cross-sectional study of 420 family medicine clinicians in 110 care teams in a Midwest health system, using administrative data from January 1, 2017 to December 31, 2017. Poisson regression was used to examine the relationship between physician FTE% and the number of patients meeting 5 criteria included in a composite metric for diabetes management (D5). Covariates included panel size, clinician type, sex, years in practice, region, patient satisfaction, care team size, rural location, and panel complexity. Of the 420 clinicians, 167 (40%) were NP/PA staff and 253 (60%) were physicians. D5 criteria were achieved in 37.9% of NP/PA panels compared with 44.5% of physician panels ( P  < .001). In adjusted analysis, rate of patients achieving D5 was unrelated to physician FTE% on the care team ( P  = .78). Physicians had a 1.082 (95% confidence interval 1.007-1.164) times greater rate of patients with diabetes achieving D5 than NPs/PAs. Clinicians at rural locations had a .904 (.852-.959) times lower rate of achieving D5 than those at urban locations. Physicians had a greater rate of patients achieving D5 compared with NPs/PAs, but physician FTE% on the care team was unrelated to D5 outcomes. This suggests that clinician team composition matters less than team roles and the dynamics of collaborative care between members.

Objective: To test the hypothesis that a greater proportion of physician time on primary care teams are associated with decreased emergency department (ED) visits, hospital admissions, and readmissions, and to determine clinician and care team characteristics associated with greater utilization., Patients and Methods: We retrospectively analyzed administrative data collected from January 1 to December 31, 2017, of 420 family medicine clinicians (253 physicians, 167 nurse practitioners/physician assistants [NP/PAs]) with patient panels in an integrated health system in 59 Midwestern communities serving rural and urban areas in Minnesota, Wisconsin, and Iowa. These clinicians cared for 419,581 patients through 110 care teams, with varying numbers of physicians and NP/PAs. Primary outcome measures were rates of ED visits, hospitalizations, and readmissions., Results: The proportion of physician full-time equivalents on the team was unrelated to rates of ED visits (rate ratio [RR] = 0.826; 95% confidence interval [CI], 0.624 to 1.063), hospitalizations (RR = 0.894; 95% CI, 0.746 to 1.072), or readmissions (RR = -0.026; 95% CI, 0.364 to 0.312). In separate multivariable models adjusted for clinician and practice-level characteristics, the rate of ED visits was positively associated with mean panel hierarchical condition category (HCC) score, urban vs rural setting, NP/PA vs physician, and lower years in practice. The rate of inpatient admissions was associated with HCC score, and 30-day hospital readmissions were positively associated with HCC score, lower years in practice, and male clinicians., Conclusion: Care team physician and NP/PA composition was not independently related to utilization. More complex panels had higher rates of ED visits, hospitalization, and readmissions. Statistically significant differences between physician and NP/PA panels were only evident for ED visits., (© 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.)

Purpose: To assess differences in Patient Aligned Care Team (PACT) performance between rural and urban primary care clinics within the Veterans Health Administration (VHA)., Methods: An Explanatory Sequential Mixed Methods design was conducted using VHA administrative data to assess performance of a national sample of 891 VHA primary care clinics. Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and process-oriented endpoints including: chronic disease management through telehealth; use of telephone visits, group visits or secured messaging; same-day access; continuity with primary care provider; and postdischarge follow-up. Qualitative data collected during on-site visits with 5 clinics were used to provide insights into PACT processes from the perspectives of staff in rural and urban clinics., Findings: After adjusting for patient- and practice-level characteristics, clinics located in large rural or small/isolated rural areas demonstrated difficulty enhancing access through use of telephone visits, group visits, or secured messaging and completing postdischarge follow-up calls, compared to urban clinics. Qualitative analysis indicated that staff from both rural and urban clinics reported similar barriers implementing these PACT processes. Both patient and staff behaviors and preferences impact implementation of these processes. Distance to care and access to high-speed Internet were also reported as barriers., Conclusions: This study contributes to the understanding of PACT performance in rural settings by highlighting ways contextual and behavioral factors relate to performance. Increasing implementation of patient-centered medical home (PCMH) models, such as PACT, will require additional attention to the complex relationships between the practice and surrounding context., (© 2020 National Rural Health Association.)

Objective: The aim of this study was to analyze perceptions and experiences of clinicians implementing the patient-centered medical home (PCMH)., Background: The PCMH model focuses on several important concepts, including team-based care management as well as care coordination and continuity among providers and across settings of care., Methods: A qualitative analysis of data collected in 2016 from primary care personnel through a national survey was conducted., Results: Four themes were found consistent with care management and care coordination: the importance of teamwork and optimized team member roles, need for adequate prioritization of care management and care coordination, need to refine tools and resources supporting care management and care coordination, and challenges with managing and coordinating care with and across complex systems., Conclusions: Successful implementation requires adequate support for teamwork and ensuring team members can work according to their clinical competency. Nurses practicing in expanded roles need clear role guidelines and adequate time to function in these roles.

Introduction: Chronic kidney disease (CKD) is widely prevalent, associated with morbidity and mortality, but may be lessened with timely implementation of evidence-based strategies including blood pressure (BP) control. Nonetheless, an evidence-practice gap persists. We synthesize the evidence for clinician-facing interventions to improve hypertension management in CKD patients in primary care., Methods: Electronic databases and related publications were queried for relevant studies. We used a conceptual model to address heterogeneity of interventions. We conducted a quantitative synthesis of interventions on blood pressure (BP) outcomes and a narrative synthesis of other CKD relevant clinical outcomes. Planned subgroup analyses were performed by (1) study design (randomized controlled trials (RCTs) or nonrandomized studies (NRS)); (2) intervention type (guideline-concordant decision support, shared care, pharmacist-facing); and (3) use of behavioral/implementation theory., Results: Of 2704 manuscripts screened, 73 underwent full-text review; 22 met inclusion criteria. BP target achievement was reported in 15 and systolic BP reduction in 6 studies. Among RCTs, all interventions had a significant effect on BP control, (pooled OR 1.21; 95% CI 1.07 to 1.38). Subgroup analysis by intervention type showed significant effects for guideline-concordant decision support (pooled OR 1.19; 95% CI 1.12 to 1.27) but not shared care (pooled OR 1.71; 95% CI 0.96 to 3.03) or pharmacist-facing interventions (pooled OR 1.04; 95% CI 0.82 to 1.34). Subgroup analysis finding was replicated with pooling of RCTs and NRS. The five contributing studies showed large and significant reduction in systolic BP (pooled WMD - 3.86; 95% CI - 7.2 to - 0.55). Use of a behavioral/implementation theory had no impact, while RCTs showed smaller effect sizes than NRS., Discussion: Process-oriented implementation strategies used with guideline-concordant decision support was a promising implementation approach. Better reporting guidelines on implementation would enable more useful synthesis of the efficacy of CKD clinical interventions integrated into primary care., Prospero Registration Number: CRD42018102441.

Objective: To determine the relationship of the emotional exhaustion domain of burnout with care team composition in a Midwestern primary care practice network., Participants and Methods: We studied 420 family medicine clinicians (253 physicians and 167 nurse practitioners/physician assistants [NP/PAs]) within a large integrated health system throughout 59 Midwestern communities. The observational cross-sectional study utilized a single-question clinician self-assessment of the emotional exhaustion domain of burnout on a scale of 0 (never) to 6 (daily) conducted between March 1 and April 2, 2018, and administrative data collected between January 1, 2017, and December 31, 2017. We used a multivariable linear mixed model for data analysis, adjusted for clinical- and team-level factors, including clinician sex, panel size and complexity, clinician type (physician or NP/PA), clinician full-time equivalent (FTE), total care team panel size, and number of clinicians on the care team., Results: Among 217 survey respondents (51.7%), the median frequency of the emotional exhaustion domain of burnout was once per week. Adjusted analyses revealed that a greater proportion of physician FTE on the care team was associated with a lower emotional exhaustion domain of burnout among individual clinicians ( P =.05). Female clinicians had a higher emotional exhaustion domain of burnout than male clinicians ( P =.05). None of the other variables in the model were associated with emotional exhaustion., Conclusion: Primary care teams containing both physicians and NP/PAs had lower levels of emotional exhaustion with increasing proportion of physician FTE. More work is needed to explore what other variables may be associated with burnout in primary care team-based practices., (© 2020 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc.)

Importance: Despite advances in cancer treatment and cancer-related outcomes, disparities in cancer mortality remain. Lower rates of cancer prevention screening and consequent delays in diagnosis may exacerbate these disparities. Better understanding of the association between area-level social determinants of health and cancer screening may be helpful to increase screening rates., Objective: To examine the association between area deprivation, rurality, and screening for breast, cervical, and colorectal cancer in patients from an integrated health care delivery system in 3 US Midwest states (Minnesota, Iowa, and Wisconsin)., Design, Setting, and Participants: In this cross-sectional study of adults receiving primary care at 75 primary care practices in Minnesota, Iowa, and Wisconsin, rates of recommended breast, cervical, and colorectal cancer screening completion were ascertained using electronic health records between July 1, 2016, and June 30, 2017. The area deprivation index (ADI) is a composite measure of social determinants of health composed of 17 US Census indicators and was calculated for all census block groups in Minnesota, Iowa, and Wisconsin (11 230 census block groups). Rurality was defined at the zip code level. Using multivariable logistic regression, this study examined the association between the ADI, rurality, and completion of cancer screening after adjusting for age, Charlson Comorbidity Index, race, and sex (for colorectal cancer only)., Main Outcomes and Measures: Completion of recommended breast, cervical, and colorectal cancer screening., Results: The study cohorts were composed of 78 302 patients eligible for breast cancer screening (mean [SD] age, 61.8 [7.1] years), 126 731 patients eligible for cervical cancer screening (mean [SD] age, 42.6 [13.2] years), and 145 550 patients eligible for colorectal cancer screening (mean [SD] age, 62.4 [7.0] years; 52.9% [77 048 of 145 550] female). The odds of completing recommended screening were decreased for individuals living in the most deprived (highest ADI) census block group quintile compared with the least deprived (lowest ADI) quintile: the odds ratios were 0.51 (95% CI, 0.46-0.57) for breast cancer, 0.58 (95% CI, 0.54-0.62) for cervical cancer, and 0.57 (95% CI, 0.53-0.61) for colorectal cancer. Individuals living in rural areas compared with urban areas also had lower rates of cancer screening: the odds ratios were 0.76 (95% CI, 0.72-0.79) for breast cancer, 0.81 (95% CI, 0.79-0.83) for cervical cancer, and 0.93 (95% CI, 0.91-0.96) for colorectal cancer., Conclusions and Relevance: Individuals living in areas of greater deprivation and rurality had lower rates of recommended cancer screening, signaling the need for effective intervention strategies that may include improved community partnerships and patient engagement to enhance access to screening in highest-risk populations.

Introduction: There is a considerable implementation gap in managing early stage chronic kidney disease (CKD) in primary care despite the high prevalence and risk for increased morbidity and mortality associated with CKD. This systematic review aims to synthesise the evidence of efficacy of implementation interventions aimed at primary care practitioners (PCPs) to improve CKD identification and management. We further aim to describe the interventions' behavioural change components., Methods and Analysis: We will conduct a systematic review of studies from 2000 to October 2017 that evaluate implementation interventions targeting PCPs and which include at least one clinically meaningful CKD outcome. We will search several electronic data bases and conduct reference mining of related systematic reviews and publications. An interdisciplinary team will independently and in duplicate, screen publications, extract data and assess the risk of bias. Clinical outcomes will include all clinically meaningful medical management outcomes relevant to CKD management in primary care such as blood pressure, chronic heart disease and diabetes target achievements. Quantitative evidence synthesis will be performed, where possible. Planned subgroup analyses include by (1) study design, (2) length of follow-up, (3) type of intervention, (4) type of implementation strategy, (5) whether a behavioural or implementation theory was used to guide study, (6) baseline CKD severity, (7) patient minority status, (8) study location and (9) academic setting or not., Ethics and Dissemination: Approval by research ethics board is not required since the review will only include published and publicly accessible data. Review findings will inform a future trial of an intervention to promote uptake of CKD diagnosis and treatment guidelines in our primary care setting and the development of complementary tools to support its successful adoption and implementation. We will publish our findings in a peer-reviewed journal and develop accessible summaries of the results., Prospero Registration Number: CRD42018102441., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Team-based care has been identified as a key component in transforming primary care. An important factor in implementing team-based care is the requirement for teams to have daily huddles. During huddles, the care team, comprising physicians, nurses, and administrative staff, come together to discuss their daily schedules, track problems, and develop countermeasures to fix these problems. However, the impact of these huddles on staff burnout over time and patient outcomes are not clear. Further, there are challenges to implementing huddles in fast-paced primary care clinics. We will test whether the impact of a behavioral intervention of leadership training and problem-solving during the daily huddling process will result in higher consistent huddling in the intervention arm and result in higher team morale, reduced burnout, and improved patient outcomes., Methods/design: We will conduct a care-team-level cluster randomized trial within primary care practices in two Midwestern states. The intervention will comprise a 1-day training retreat for leaders of primary care teams, biweekly sessions between huddle optimization coaches and members of the primary care teams, as well as coaching site visits at 30 and 100 days post intervention. This behavioral intervention will be compared to standard care, in which care teams have huddles without any support or training. Surveys of primary care team members will be administered at baseline (prior to training), 100 days (for the intervention arm only), and 180 days to assess team dynamics. The primary outcome of this trial will be team morale. Secondary outcomes will assess the impact of this intervention on clinician burnout, patient satisfaction, and quality of care., Discussion: This trial will provide evidence on the impact of a behavioral intervention to implement huddles as a key component of team-based care models. Knowledge gained from this trial will be critical to broader deployment and successful implementation of team-based care models., Trial Registration: Clinicaltrials.gov , NCT03062670 . Registered on 23 February 2017.

International implementation of the patient-centered medical home (PCMH) model for delivering primary care has dramatically increased in the last decade. A majority of research on PCMH's impact has emphasized the care provided by clinically trained staff. In this article, we report our ethnographic analysis of data collected from Department of Veterans Affairs staff implementing PACT, the VA version of PCMH. Teams were trained to use within-team delegation, largely accomplished through attention to clinical licensure, to differentiate staff in providing efficient, patient-centered care. In doing so, PACT may reinforce a clinically defined culture of care that countermands PCMH ideals. Such competing rubrics for care are brought into relief through a focus on the care work performed by clerks. Ethnographic analysis identifies clerks' care as a kind of emotional dirty work, signaling important areas for future anthropological study of the relationships among patient-centered care, stigma, and clinical authority., (© 2016 by the American Anthropological Association.)

In this paper we present results of a mixed methods study conducted to identify barriers to team function among staff implementing patient aligned care teams - the Department of Veterans Affairs' patient centered medical home (PCMH) model. Using a convergent mixed methods design, we administered a standardized survey measure (Team and Individual Role Perception Survey) to assess work role challenge and engagement; and conducted discussion groups to gather context pertaining to role change. We found that the role of primary care providers is highly challenging and did not become less difficult over the initial year of implementation. Unexpectedly over the course of the first year nurse care managers reported a decrease in their perceptions of empowerment and clerical associates reported less skill variety. Qualitative data suggest that more skilled team members fail to delegate and share tasks within their teams. We characterize this interprofessional knowledge factor as an empowerment paradox where team members find it difficult to share tasks in ways that are counter to traditionally structured hierarchical roles. Health care systems seeking to implement PCMH should dedicate resources to facilitating within-team role knowledge and negotiation.

Introduction: This study reports on physicians' experiences in conducting end-of-life conversations with elderly patients who suffered from multiple co-morbidities (MCM). Our hypothesis was that both the lack of prognostic certainty and the lack of good communication tools contributed to physicians' discomfort with conducting EOL conversations with patients and families of patients with these conditions especially when compared with patients and families of patients who had a single, clear terminal diagnosis (e.g. pancreatic cancer)., Methods: Focus group questions were semi-structured and explored three general themes: (1) differences between having an end-of-life conversation with patients/families with MCM versus those with a single, terminal diagnosis; (2) timing of the end-of-life conversation; and (3) approaches to the end-of-life conversation., Results: Three themes emerged: (1) It is more difficult for them to have EOL conversations with patients with MCM and their families, as opposed to conversations with families and patients who have a clear, terminal diagnosis. (2) In deciding when to raise the subject of EOL care, participants reported that they rely on a number of physical and/or social signs to prompt these discussions. Yet a major reason for the difficulty that providers face in initiating these discussions with MCM patients and families is that there is a lack of a clear threshold or prompting event. (3) Participants mentioned three types of approaches to initiating EOL conversations: (a) direct approach, (b) indirect approach, (c) collaborative approach., Conclusion: Prognostic indicies and communication scripts may better prepare physicians to facilitate end-of-life conversations with MCM patients/families.