A Systematic Approach to Identifying and Developing Implementation Strategies to Support the Uptake of a Risk Tool to Aid in Clinical Management of Patients with Syncope: A Qualitative Study

Background: The Canadian Syncope Risk Score (CSRS) is a validated risk stratification tool developed to optimize the accuracy of emergency department decisions and inform evidence-based clinical actions. While preliminary work has been undertaken to understand the barriers to CSRS use, no work to date has explored how to implement the CSRS to overcome these barriers in practice. This study aimed to identify which implementation strategies are most appropriate to address these barriers and how they should be implemented to mitigate the possibility of poor uptake. Methods: We conducted a series of three iterative online user-centered design workshops with emergency medicine physicians from three hospital sites in Ontario, Canada. The objective of the workshops was to engage participants in identifying acceptable strategies to promote CSRS uptake and how they should be operationalized. To support this, we systematically mapped previously identified barriers to corresponding behaviour change techniques to identify the most likely strategies to effect change. The sessions were audio-recorded and dialogue relating directly to the study objective were transcribed. We performed a qualitative content data analysis according to pre-defined objectives for each workshop. Results: Fourteen physicians participated across the three workshops. The main implementation strategies identified to overcome identified barriers were: education in the format of meetings, videos, journal clubs, and posters (uncertainty around when and how to apply the CSRS); an online calculator and integration of the CSRS into electronic medical record (uncertainty in how to apply the CSRS), local champion (lack of team buy-in); and dissemination of evidence summaries and feedback through email communications (lack of evidence about impact). Conclusions: The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure the CSRS is well-positioned for impact, a comprehensive suite of implementation strategies was identified to address known barriers. This next phase of work will provide insight into whether these strategies facilitated better alignment with barriers, higher physician engagement with the implementation strategies, and broader uptake of the CSRS, with the objective of improving the likelihood that the CSRS will positively influence patient outcomes.

Infectious Disease Providers’ Knowledge of and Engagement in Quality Improvement

Background Although engagement of infectious disease physicians has been demonstrated to improve clinical outcomes in a variety of disease states, the extent of ID physician engagement in quality improvement or their knowledge of QI has not been assessed. Methods A 12 question, web-based survey was distributed to members of the Infectious Disease Society of America between August and October 2019 to assess knowledge of and engagement in QI. The survey link was sent to IDSA members that self-identified patient care as their primary professional activity. Results Responses were received from 200 individuals (5.4% response rate which is just below standard IDSA survey response rate of 6%) consisting of 175 adult IDP. Most respondents were employed in a hospital or clinic (41%), private or group practice (25%), or university/medical center (24%). 58% of respondents currently participate in QI projects while 38% serve on QI oversight committees. Among respondents, 27% reported not being engaged in QI. Infection Prevention/Hospital Epidemiology (77%), stewardship (72%), and antimicrobial resistance (56%) were the most commonly reported measure types. Respondents reported barriers that limited participation in QI including cost (61%), lack of time (56%), lack of data collection resources (48%), and lack of an ID-specific registry (46%). IDPs report significant interest in additional training in QI and new quality measures. Conclusion Although IDPs participate in QI, there are gaps in QI knowledge and measurement systems. The low response rate of our survey also suggests a lack of engagement in QI amongst IDPs. Closing these gaps will benefit ID in a value-driven healthcare economy.

Socially situated risk: challenges and strategies for implementing algorithmic risk scoring for care management

Objective To characterize challenges and strategies related to algorithmic risk scoring for care management eligibility determinations. Materials and Methods Interviews with 19 administrators from 13 physician organizations representing over 2200 physician offices and 8800 physicians in Michigan. Post-implementation interviews were coded using thematic analysis. Results Utility of algorithmic risk scores was limited due to outdated claims or incomplete information about patients’ socially situated risks (eg, caregiver turnover, social isolation). Resulting challenges included lack of physician engagement and inefficient use of staff time reviewing eligibility determinations. To address these challenges, risk scores were supplemented with physician knowledge and clinical data. Discussion and Conclusion Current approaches to risk scoring based on claims data for payer-led programs struggle to gain physician acceptance and support because of data limitations. To respond to these limitations, physician input regarding socially situated risk and utilization of more timely data may improve eligibility determinations.

Application of the community dialogues method to identify ethical values and priorities related to pharmacogenomics

Given the expansion of genetics in medicine, there is a growing need to develop approaches to engage patients in understanding how genetics affects their health. Various qualitative methods have been applied to gain a deeper understanding of patient perspectives in topics related to genetics. Community dialogues (CD) are a bi-directional research method that invites community members to discuss a pertinent, challenging topic over the course of a multi-week period and the community members openly discuss their positions on the topic. Authors discuss the first application of the CD method to the topic of pharmacogenetics testing. Additional CD are needed to engage diverse participant populations on this topic to improve genetics literacy, enhance physician engagement and drive policy change.

Practice transformation at scale through a microsystems quality improvement (QI) approach.

e18667 Background: How oncology providers should implement practice transformation for value-based care is unclear, particularly at scale. Organizational size enables efficient “top down” approaches, but also presents challenges such as physician engagement. Dis-economies of scale can be acute in oncology due to physician autonomy and coordination costs. We hypothesized that organizational change based in sense-making models that enhance physician engagement and use a decentralized, iterative microsystems approach will enable practice transformation to scale. Methods: Florida Cancer Specialists & Research Institute (FCS) is a physician led 250-oncologist statewide practice, with regional variation in disease state/mix, patient cohort, etc., making a purely top-down approach to organizational change infeasible. FCS prototyped a transformation strategy starting in June 2017 based on sharing interpreted data with physician and executive leadership. Later implementation directly engaged physicians in a microsystems quality QI strategy focused on regional performance. Interventions targeted disease, health service utilization, location, and individual physicians. Performance was evaluated using data from Medicare’s Oncology Care Model (OCM) and assessed using the one-sided risk target (4% below benchmark). We analyzed 70,239 performance period (PP) episodes at FCS across 35,116 patients. Results: In the pre- intervention period (90% of PP1 episodes, completed by June 2017), FCS was 5.8% above target. Performance was 10.9% above target for the remainder of PP1 (10% of PP1 episodes), then improved to 0.3% above target in PP2 and PP3, and below target by 0.9%, 0.8%, and 0.75% in PP4, PP5, and PP6. Early QI efforts focused on performance in lung cancer, which was 2.5% over target in PP1; it improved to 2.1% under target in PP6. Later regional QI sessions targeted cancer, utilization and providers. Pre-intervention, all 18 regions were above target; by PP6, 11 out of 19 regions were below target. Relative to the pre-intervention period, per-episode inpatient costs increased by 12.1% for the remainder of PP1 and increased by 4.3% and 1.3% in PP2 and PP6; inpatient costs decreased in PP3, PP4, and PP5 by 3.8%, 2.4% and 4.8%. Conclusions: Practice transformation in oncology can achieve scale through models of organizational change that foster physician engagement. Data, when clinically contextualized, is a foundational tool in the sense-making process. Scale can develop through an additive microsystems approach in which QI units are de-centralized, accountability is defined, and iteration becomes part of organizational culture. [Table: see text]