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Search Results: 1 - 10 of 407689 matches for " Elizabeth M Yano "
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The role of organizational research in implementing evidence-based practice: QUERI Series
Elizabeth M Yano
Implementation Science , 2008, DOI: 10.1186/1748-5908-3-29
Abstract: Using the six-step QUERI process as a foundation, we present an organizational research framework designed to improve and accelerate the implementation of evidence-based practice into routine care. Specific QUERI-related organizational research applications are reviewed, with discussion of the measures and methods used to apply them. We describe these applications in the context of a continuum of organizational research activities to be conducted before, during and after implementation.Since QUERI's inception, various approaches to organizational research have been employed to foster progress through QUERI's six-step process. We report on how explicit integration of the evaluation of organizational factors into QUERI planning has informed the design of more effective care delivery system interventions and enabled their improved "fit" to individual VA facilities or practices. We examine the value and challenges in conducting organizational research, and briefly describe the contributions of organizational theory and environmental context to the research framework.Understanding the organizational context of delivering evidence-based practice is a critical adjunct to efforts to systematically improve quality. Given the size and diversity of VA practices, coupled with unique organizational data sources, QUERI is well-positioned to make valuable contributions to the field of implementation science. More explicit accommodation of organizational inquiry into implementation research agendas has helped QUERI researchers to better frame and extend their work as they move toward regional and national spread activities.Health care organizations exert significant influence on the quality of care through an array of factors that directly or indirectly serve as the context in which clinicians practice and patients experience care [1]. A greater understanding of this context can be important in closing the gap between research and practice. Each health care setting into which innov
'To take care of the patients': Qualitative analysis of Veterans Health Administration personnel experiences with a clinical informatics system
Laura M Bonner, Carol E Simons, Louise E Parker, Elizabeth M Yano, JoAnn E Kirchner
Implementation Science , 2010, DOI: 10.1186/1748-5908-5-63
Abstract: As part of an evaluation of a quality improvement initiative, we interviewed 72 VA clinicians and managers using a semi-structured interview format. We conducted a qualitative analysis of interview transcripts, examining themes relating to participants' interactions with and evaluations of the VA EHR.Participants described their perceptions of the positive and negative effects of the EHR on their clinical workflow. Although they appreciated the speed and ease of documentation that the EHR afforded, they were concerned about the time cost of using the technology and the technology's potential for detracting from interpersonal interactions.VA personnel value EHRs' contributions to supporting communication, education, and documentation. However, participants are concerned about EHRs' potential interference with other important aspects of healthcare, such as time for clinical care and interpersonal communication with patients and colleagues. We propose that initial implementation of an EHR is one step in an iterative process of ongoing quality improvement.Recent research and national healthcare policy discussions have highlighted the potential of electronic health records (EHRs) to improve quality and efficiency [1-3] and potentially to reduce healthcare costs [4,5]. Many large healthcare organizations have implemented some form of healthcare informatics, but few have comprehensive systems [6]. EHRs have been difficult to implement [7], and their cost-effectiveness remains unclear [8-10]. For example, the British National Health Service has experienced 'costly delays' in implementation of its EHR [11]. Researchers have identified many barriers to implementation, including increased documentation time [12,13], interference with clinical workflow, apprehension about unintended negative consequences, financial concerns, physician resistance, maintenance costs, and inadequate information technology (IT) staff to support implementation, among others [6,14,15].The Plan-Do-Stu
Comparing strategies for United States veterans' mortality ascertainment
Karl A Lorenz, Steven M Asch, Elizabeth M Yano, Mingming Wang, Lisa V Rubenstein
Population Health Metrics , 2005, DOI: 10.1186/1478-7954-3-2
Abstract: We constructed a cohort of California veterans who died in fiscal year (FY) 2000 and used VA services the year before death. We determined decedent status using California death certificates linked to VA utilization data and the VA Beneficiary Identification and Records Locator System (BIRLS) death file. We compared the characteristics of decedents who would not have been identified by either single source (e.g., VA BIRLS alone or California death certificates alone) with the rest of the cohort.A total of 8,813 veteran decedents were identified from both VA decedent files and death certificates. Of all decedents, 5,698 / 8,813 (65%) veterans were identified in both source files, but 2,426 / 8,813 (28%) decedents were not identified in VA BIRLS, and 689 / 8,813 (8%) were not identified in death certificates. Compared to the rest of the cohort, decedents whose mortality status was ascertained through either single source differed by race / ethnicity, marital status, and California residence. Clinically, veterans identified from either single source had less comorbidity and were less likely to have been users of VA inpatient or long term care, but equally or more likely to have been users of VA outpatient services.As single sources, VA decedent files and death certificates each provided an incomplete record, and death ascertainment was improved by using both source files. Potential bias may vary depending on analytic interest.Clinicians, healthcare administrators, researchers, regulators and policymakers are concerned with optimizing mortality ascertainment using administrative data. In addition to its clinical importance, mortality informs program planning, quality assessment and improvement, and public reporting [1-8]. Veterans are an important, vulnerable population in which mortality has been examined as a function of race / ethnicity, service characteristics, access, and quality of care. Valid, complete reporting is critical to the success of such endeavors, and l
A social marketing approach to implementing evidence-based practice in VHA QUERI: the TIDES depression collaborative care model
Jeff Luck, Fred Hagigi, Louise E Parker, Elizabeth M Yano, Lisa V Rubenstein, JoAnn E Kirchner
Implementation Science , 2009, DOI: 10.1186/1748-5908-4-64
Abstract: The approach relied on a sequential model of behavior change and explicit attention to audience segmentation. Segments included VHA national leadership, Veterans Integrated Service Network (VISN) regional leadership, facility managers, frontline providers, and veterans. TIDES communications, materials and messages targeted each segment, guided by an overall marketing plan.Depression collaborative care based on the TIDES model was adopted by VHA as part of the new Primary Care Mental Health Initiative and associated policies. It is currently in use in more than 50 primary care practices across the United States, and continues to spread, suggesting success for its social marketing-based dissemination strategy.Development, execution and evaluation of the TIDES marketing effort shows that social marketing is a promising approach for promoting implementation of evidence-based interventions in integrated healthcare systems.Implementing evidence-based interventions in a healthcare provider organization is a challenging endeavor, requiring changes in attitudes, beliefs and behavior [1]. Mandating change may be a seemingly simple course of action, but is rarely effective [2-4], especially because clinicians have a strong occupational culture and enjoy a high degree of professional autonomy in healthcare organizations [5]. Rather, change is most likely to occur when organizational members' attitudes and beliefs are concordant with the desired change, and they are willing to behave accordingly.These challenges are amplified in an integrated healthcare organization with multiple points of care (sites) that exhibit significant variation in local cultures and circumstances. For example, USA's Veterans Health Administration (VHA) is a nationwide system of outpatient facilities and medical centers, which is organized into 21 regional Veterans Integrated Service Networks (VISNs) and supervised by a national Central Office [6]. Therefore, successful national implementation in VHA dep
Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system
David A Ganz, Elizabeth M Yano, Debra Saliba, Paul G Shekelle
BMC Health Services Research , 2009, DOI: 10.1186/1472-6963-9-206
Abstract: We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.Falls are common in older people, occurring annually in one quarter to one third of community-dwelling adults age ≥ 65 [1]. These falls pose a serious problem, both because of associated injuries (e.g., hip fractures) [2] and because of the falls' psychological impact on patients [3]. Older adults may restrict their activities in response to a fall, leading to a loss of independence and ability to carry out life's routine tasks. Research evidence has shown that both gentle exercise to improve strength and balance and multifactorial fall prevention programs can reduce future falls in community-dwelling older adults who participate in randomized, controlled trials [4,5]. These
Determinants of successful clinical networks: the conceptual framework and study protocol
Mary Haines, Bernadette Brown, Jonathan Craig, Catherine D'Este, Elizabeth Elliott, Emily Klineberg, Elizabeth McInnes, Sandy Middleton, Christine Paul, Sally Redman, Elizabeth M Yano, on behalf of Clinical Networks Research Group
Implementation Science , 2012, DOI: 10.1186/1748-5908-7-16
Abstract: The objective of this retrospective study is to examine the association between external support, organisational and program factors, and indicators of success among 19 clinical networks over a three-year period (2006-2008). The outcomes (health impact, system impact, programs implemented, engagement, user perception, and financial leverage) and explanatory factors will be collected using a web-based survey, interviews, and record review. An independent expert panel will provide judgements about the impact or extent of each network's initiatives on health and system impacts. The ratings of the expert panel will be the outcome used in multivariable analyses. Following the rating of network success, a qualitative study will be conducted to provide a more in-depth examination of the most successful networks.This is the first study to combine quantitative and qualitative methods to examine the factors that contribute to the success of clinical networks and, more generally, is the largest study of clinical networks undertaken. The adaptation of expert panel methods to rate the impacts of networks is the methodological innovation of this study. The proposed project will identify the conditions that should be established or encouraged by agencies developing clinical networks and will be of immediate use in forming strategies and programs to maximise the effectiveness of such networks.It is widely accepted that patients who receive evidence-based care achieve better outcomes. However, despite increases in more rigorous clinically relevant research, the slow and haphazard uptake or failure to adopt such evidence into practice persists [1,2].Clinical networks are more commonly being viewed as an important strategy for increasing evidence-based practice and improving models of care [3]. It is argued that clinical networks provide 'bottom up' views on the best ways to tackle complex healthcare problems and can facilitate or champion changes in practice at the clinical interface
Prevalence and trends of selected urologic conditions for VA healthcare users
Min-Woong Sohn, Huiyuan Zhang, Brent C Taylor, Michael J Fischer, Elizabeth M Yano, Christopher Saigal, Timothy J Wilt, the Urologic Diseases in America Project
BMC Urology , 2006, DOI: 10.1186/1471-2490-6-30
Abstract: VHA administrative files for 1999 – 2002 and Medicare claims files for the same years were used to identify those who had a diagnosis of qualifying urologic conditions.Among the conditions evaluated, prostate cancer was listed as a primary diagnosis for 5.4% of VHA users in 2002, followed in decreasing prevalence by erectile dysfunction (2.9%), renal mass (1.5%), interstitial cystitis (1.4%), and prostatitis (1.1%). Age-adjusted rates showed significant increases for renal mass (31%), interstitial cystitis (14%), and erectile dysfunction (8%) between 1999 and 2002. Systematic variations in prevalence rates and trends were observed by age, race/ethnicity, and region. Those in the Western region generally had lower age-adjusted prevalence rates and their increases were also slower than other regions. Addition of Medicare data resulted in large increases (21 to 489%) in prevalence among VHA users, suggesting substantial amount of non-VA urological care provided to VHA users.Prevalence rates for many urologic diseases increased between 1999 and 2002, which were not entirely attributable to the aging of veterans. This changing urologic disease burden has substantial implications for access to urologic care and treatment capacity, especially in light of the level of urologic care delivered to veterans by Medicare providers outside the VA. Further study on the factors associated with these increases and how they affect the patterns, cost, and quality of care in veterans is needed.Urologic diseases can result in considerable morbidity, mortality and healthcare resource utilization [1-5]. An accurate estimation of their prevalence is crucial in predicting future costs and demands for related services, understanding patterns of care and planning for resources needed to meet the demand.The objective of this study is to describe the prevalence rates of urologic cancers and selected benign urologic conditions and their trends between 1999 and 2002 for those who have been using h
Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign
Edmund F Chaney, Lisa V Rubenstein, Chuan-Fen Liu, Elizabeth M Yano, Cory Bolkan, Martin Lee, Barbara Simon, Andy Lanto, Bradford Felker, Jane Uman
Implementation Science , 2011, DOI: 10.1186/1748-5908-6-121
Abstract: The study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.Interviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).Depression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.ClinicalTrials.gov: NCT00105820Despite efficacious therapies, depression remains a
Implementation of automated reporting of estimated glomerular filtration rate among Veterans Affairs laboratories: a retrospective study
Rasheeda K Hall, Virginia Wang, George L Jackson, Bradley G Hammill, Matthew L Maciejewski, Elizabeth M Yano, Laura P Svetkey, Uptal D Patel
BMC Medical Informatics and Decision Making , 2012, DOI: 10.1186/1472-6947-12-69
Abstract: We performed a retrospective observational study of laboratories in VHA facilities from July 2004 to September 2009. Using laboratory data, we identified the status of implementation of automated eGFR reporting for each facility and the time to actual implementation from the date the VHA adopted its policy for automated eGFR reporting. Using survey and administrative data, we assessed facility organizational characteristics associated with implementation of automated eGFR reporting via bivariate analyses.Of 104 VHA laboratories, 88% implemented automated eGFR reporting in existing laboratory IT systems by the end of the study period. Time to initial implementation ranged from 0.2 to 4.0 years with a median of 1.8 years. All VHA facilities with on-site dialysis units implemented the eGFR software (52%, p<0.001). Other organizational characteristics were not statistically significant.The VHA did not have uniform implementation of automated eGFR reporting across its facilities. Facility-level organizational characteristics were not associated with implementation, and this suggests that decisions for implementation of this software are not related to facility-level quality improvement measures. Additional studies on implementation of laboratory IT, such as automated eGFR reporting, could identify factors that are related to more timely implementation and lead to better healthcare delivery.
Serogroups and virulence genotypes of Escherichia coli isolated from patients with sepsis
Ananias, M.;Yano, T.;
Brazilian Journal of Medical and Biological Research , 2008, DOI: 10.1590/S0100-879X2008001000008
Abstract: sixty strains of escherichia coli, isolated by hemoculture, from septicemic brazilian patients were evaluated to determine their serogroup and invasivity to vero cells. all 60 patients died within 2 days of hospitalization. furthermore, the molecular study of the following extraintestinal pathogenic e. coli-associated virulence factor (vf) genes was performed by pcr: i) adhesins: type 1 fimbria (fimh), s fimbria (sfad/e), p fimbria (papc and papg alleles) and afimbrial adhesin (afab/c); ii) capsule k1/k5 (kpsmtii); iii) siderophores: aerobactin (iucd), yersiniabactin (fyua) and salmochelin (iron); iv) toxins hemolysin (hlya), necrotizing cytotoxic factor type 1 (cnf1) and secreted autotransporter toxin (sat); v) miscellaneous: brain microvascular endothelial cells invasion (ibea), serum resistance (trat), colicin v (cvac) and specific uropathogenic protein (usp). our results showed that isolates are able to invade vero cells (96.6%), differing from previous research on uropathogenic e. coli (upec). the o serogroups associated with upec were prevalent in 60% of strains vs 11.7% of other serogroups. the pcr results showed a conserved virulence subgroup profile and a prevalence above 75% for fimh, fyua, kpsmtii and iucd, and between 35-65% for papc, papg, sat, iron, usp and trat. the evasion from the immunological system of the host and also iron uptake are essential for the survival of extraintestinal pathogenic e. coli strains. interestingly, among our isolates, a low prevalence of vf genes appeared. therefore, the present study contributes to the identification of a bacterial profile for sepsis-associated e. coli.
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