Browsing by Author "Epling, John W."

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    Clinical Management of Low Vitamin D: A Scoping Review of Physician's Practices
    Rockwell, Michelle S.; Kraak, Vivica; Hulver, Matthew W.; Epling, John W. (MDPI, 2018-04-16)
    The role of vitamin D in the prevention and treatment of non-skeletal health issues has received significant media and research attention in recent years. Costs associated with clinical management of low vitamin D (LVD) have increased exponentially. However, no clear evidence supports vitamin D screening to improve health outcomes. Authoritative bodies and professional societies do not recommend population-wide vitamin D screening in community-dwelling adults who are asymptomatic or at low risk of LVD. To assess patterns of physicians’ management of LVD in this conflicting environment, we conducted a scoping review of three electronic databases and the gray literature. Thirty-eight records met inclusion criteria and were summarized in an evidence table. Thirteen studies published between 2006 and 2015 across seven countries showed a consistent increase in vitamin D lab tests and related costs. Many vitamin D testing patterns reflected screening rather than targeted testing for individuals at high risk of vitamin D deficiency or insufficiency. Interventions aimed at managing inappropriate clinical practices related to LVD were effective in the short term. Variability and controversy were pervasive in many aspects of vitamin D management, shining a light on physicians’ practices in the face of uncertainty. Future research is needed to inform better clinical guidelines and to assess implementation practices that encourage evidence-based management of LVD in adult populations.
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    Does de-implementation of low-value care impact the patient-clinician relationship? A mixed methods study
    Rockwell, Michelle S.; Michaels, Kenan C.; Epling, John W. (2022-01-06)
    Background The importance of reducing low-value care (LVC) is increasingly recognized, but the impact of de-implementation on the patient-clinician relationship is not well understood. This mixed-methods study explored the impact of LVC de-implementation on the patient-clinician relationship. Methods Adult primary care patients from a large Virginia health system volunteered to participate in a survey (n = 232) or interview (n = 24). Participants completed the Patient-Doctor Relationship Questionnaire (PDRQ-9) after reading a vignette about a clinician declining to provide a low-value service: antibiotics for acute sinusitis (LVC-antibiotics); screening EKG (LVC-EKG); screening vitamin D test (LVC-vitamin D); or an alternate vignette about a high-value service, and imagining that their own primary care clinician had acted in the same manner. A different sample of participants was asked to imagine that their own primary care clinician did not order LVC-antibiotics or LVC-EKG and then respond to semi-structured interview questions. Outcomes data included participant demographics, PDRQ-9 scores (higher score = greater relationship integrity), and content analysis of transcribed interviews. Differences in PDRQ-9 scores were analyzed using one-way ANOVA. Data were integrated for analysis and interpretation. Results Although participants generally agreed with the vignette narrative (not providing LVC), many demonstrated difficulty comprehending the broad concept of LVC and potential harms. The topic triggered memories of negative experiences with healthcare (typically poor-quality care, not necessarily LVC). The most common recommendation for reducing LVC was for patients to take greater responsibility for their own health. Most participants believed that their relationship with their clinician would not be negatively impacted by denial of LVC because they trusted their clinician’s guidance. Participants emphasized that trusted clinicians are those who listen to them, spend time with them, and offer understandable advice. Some felt that not providing LVC would actually increase their trust in their clinician. Similar PDRQ-9 scores were observed for LVC-antibiotics (38.9), LVC-EKG (37.5), and the alternate vignette (36.4), but LVC-vitamin D was associated with a significantly lower score (31.2) (p < 0.05). Conclusions In this vignette-based study, we observed minimal impact of LVC de-implementation on the patient-clinician relationship, although service-specific differences surfaced. Further situation-based research is needed to confirm study findings.
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    Implementation of a Multimodal Heart Failure Management Protocol in a Skilled Nursing Facility
    Rockwell, Michelle S.; Cox, Emily; Locklear, Tonja; Hodges, Brandy; Mulkey, Stacey; Evans, Brandon; Epling, John W.; Stavola, Anthony R. (SAGE, 2023-02)
    Hospitals and skilled nursing facilities (SNFs) are incentivized to reduce hospital readmissions among patients with heart failure (HF). We used the RE-AIM framework and mixed quantitative and qualitative data to evaluate the implementation of a multimodal HF management protocol (HFMP) administered in a SNF in 2021. Over 90% of eligible patients were enrolled in the HFMP (REACH). Of the 42 enrolled patients (61.9% female, aged 81.9 ± 8.9 years, 9.5% Medicaid), 2 (4.8%) were readmitted within 30 days of hospital discharge and 4 (9.5%) were readmitted within 30 days of SNF discharge compared with historical (2020) rates of 16.7% and 22.2%, respectively (a potential savings of $132,418–$176,573 in hospital costs) (EFFECTIVENESS). Although stakeholder feedback about ADOPTION and IMPLEMENTATION was largely positive, challenges associated with clinical data collection, documentation, and staff turnover were described. Findings will inform refinement of the HFMP to facilitate further testing and sustainability (MAINTENANCE).
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    Practice facilitation to promote evidence-based screening and management of unhealthy alcohol use in primary care: a practice-level randomized controlled trial
    Huffstetler, Alison N.; Kuzel, Anton J.; Sabo, Roy T.; Richards, Alicia; Brooks, E. M.; Lail Kashiri, Paulette; Villalobos, Gabriela; Arias, Albert J.; Svikis, Dace; Bortz, Beth A.; Edwards, Ashley; Epling, John W.; Cohen, Deborah J.; Parchman, Michael L.; Winter, Jonathan; Wessler, Patricia; Yu, Timothy J.; Krist, Alex H. (2020-05-20)
    Background Unhealthy alcohol use is the third leading cause of preventable death in the United States. Evidence demonstrates that screening for unhealthy alcohol use and providing persons engaged in risky drinking with brief behavioral and counseling interventions improves health outcomes, collectively termed screening and brief interventions. Medication assisted therapy (MAT) is another effective method for treatment of moderate or severe alcohol use disorder. Yet, primary care clinicians are not regularly screening for or treating unhealthy alcohol use. Methods and analysis We are initiating a clinic-level randomized controlled trial aimed to evaluate how primary care clinicians can impact unhealthy alcohol use through screening, counseling, and MAT. One hundred and 25 primary care practices in the Virginia Ambulatory Care Outcomes Research Network (ACORN) will be engaged; each will receive practice facilitation to promote screening, counseling, and MAT either at the beginning of the trial or at a 6-month control period start date. For each practice, the intervention includes provision of a practice facilitator, learning collaboratives with three practice champions, and clinic-wide information sessions. Clinics will be enrolled for 6–12 months. After completion of the intervention, we will conduct a mixed methods analysis to identify changes in screening rates, increase in provision of brief counseling and interventions as well as MAT, and the reduction of alcohol intake for patients after practices receive practice facilitation. Discussion This study offers a systematic process for dissemination and implementation of the evidence-based practice of screening, counseling, and treatment for unhealthy alcohol use. Practices will be asked to implement a process for screening, counseling, and treatment based on their practice characteristics, patient population, and workflow. We propose practice facilitation as a robust and feasible intervention to assist in making changes within the practice. We believe that the process can be replicated and used in a broad range of clinical settings; we anticipate this will be supported by our evaluation of this approach. Trial registration ClinicalTrials.gov, ClinicalTrials.gov Identifier: NCT04248023, Registered 5 February 2020.
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    Socializing the evidence for diabetes control to develop “mindlines”: a qualitative pilot study
    Epling, John W.; Rockwell, Michelle S.; Miller, Allison D.; Carver, M. Colette (2021-09-07)
    Background Evidence on specific interventions to improve diabetes control in primary care is available, but this evidence is not always well-implemented. The concept of “mindlines” has been proposed to explain how clinicians integrate evidence using specifics of their practices and patients to produce knowledge-in-practice-in-context. The goal of this pilot study was to operationalize this concept by creating a venue for clinician-staff interaction concerning evidence. The research team attempted to hold “mindlines”-producing conversations in primary care practices about evidence to improve diabetes control. Methods Each of four primary care practices in a single health system held practice-wide conversations about a simple diabetes intervention model over a provided lunch. The conversations were relatively informal and encouraged participation from all. The research team recorded the conversations and took field notes. The team analyzed the data using a framework adapted from the “mindlines” research and noted additional emergent themes. Results While most of the conversation concerned barriers to implementation of the simple diabetes intervention model, there were examples of practices adopting and adapting the evidence to suit their own needs and context. Performance metrics regarding diabetes control for the four practices improved after the intervention. Conclusion It appears that the type of conversations that “mindlines” research describes can be generated with facilitation around evidence, but further research is required to better understand the limitations and impact of this intervention.
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    Trust in Healthcare and Trust in Science Predict Readiness to Receive the COVID-19 Vaccine in Appalachia
    Rockwell, Michelle S.; Stein, Jeffrey S.; Gerdes, Julie; Brown, Jeremiah; Ivory, Adrienne Holz; Epling, John W. (2021-04-06)
    BACKGROUND: The Appalachian Region faces multiple barriers to widespread COVID-19 vaccination. The purpose of this research study was to explore the role of trust in healthcare and trust in science on Appalachian residents’ readiness to receive the COVID-19 vaccine. Trust in health influencers and health information sources were also explored. METHODS: A cross sectional survey study of Appalachian Region residents (n=1048) was completed between February 25 and March 6, 2021, with equivalent rural and non-rural sampling methods employed. Participants were >35 years of age and had not received the COVID-19 vaccine at the time of survey administration. RESULTS: Overall, 31% of participants were extremely likely to receive the vaccine, while 42% were somewhat likely/neither unlikely or likely/somewhat unlikely, and 27% were extremely unlikely. Based on multiple linear regression analysis with backwards selection, trust in healthcare, trust in science, residence (rural vs. non-rural) and age were positive predictors of readiness to receive the vaccine (F(5, 1042)= 38.9, R2= 0.157, p< 0.01). Gender, education, household income, and political affiliation did not predict vaccine readiness. Trust in media for health information was modest, with ratings of none or not much for social media (64%), podcasts (61%), magazines (46%), radio (37%), newspapers (36%), and television (35%). Primary care providers emerged as the highest trusted health influencer of 15 options and a primary care provider’s office was the most common preference for location for receiving the COVID-19 vaccine, particularly in participants who rated themselves as extremely unlikely to receive the COVID-19 vaccine. CONCLUSIONS: These findings suggest that trust in healthcare and science are prospective foci for initiatives aimed at improving vaccine acceptance in Appalachia, particularly in younger residents of rural areas. As highly trusted health influencers, primary care providers should be leveraged and supported in COVID-19 vaccine education and distribution.