BACKGROUND:Providing timely follow-up care after hospitalization reduces readmissions and improves patient outcomes, yet rates for follow-up within seven days of discharge are relatively low. METHODS:The authors implemented and evaluated a statewide collaborative (formed in 2018) to improve health outcomes for Ohio's Medicaid population, including a focus on timely follow-up after hospitalization for mental illness within seven days. Interventions (initiated in 2019) included developing new clinical services, completing follow-up phone calls after discharge, reserving dedicated appointment slots for hospital follow-up visits, expanding staffing, initiating collaborative care, convening predischarge planning groups, promoting warm handoffs, and using telehealth. A longitudinal analysis using binomial regression was conducted to retrospectively evaluate quarterly Medicaid claims and eligibility data from 2019 through 2023 to assess for improvement in the percentage of persons discharged who had timely follow-up after hospitalization. To compare annual changes observed for the statewide collaborative with national trends, changes were compared with publicly available data from the National Committee for Quality Assurance (NCQA). RESULTS:The number of eligible discharges totaled 9,041 across the statewide collaborative from 2019 through 2023. The available data demonstrated improvement in timely follow-up after hospitalization for mental illness, from 47.9% in 2019 to 57.0% in 2023 (quarterly median 51.8%, for 2019-2023). In binomial regression, there was a highly significant increase in the probability of follow-up over time (p < 0.001). Compared with publicly available national payer data from NCQA, the collaborative had higher rates of follow-up (by 7.5 percentage points across the study period, p = 0.015), and the difference in trends over time was statistically significant (difference in slope = 2.15 percentage points per year, p = 0.01). CONCLUSION:A statewide learning collaborative was associated with an increased percentage of Medicaid beneficiaries receiving timely follow-up after hospitalization for mental illness.

Importance:Unhealthy alcohol use is a leading cause of preventable deaths and is associated with many societal and health problems. Fewer than one-third of people who visit primary care practices in the US are asked about or ever discuss alcohol use with a health professional. Objective:To evaluate the association between primary care practice facilitation and adoption of evidence-based screening and brief counseling for unhealthy alcohol use. Design, Setting, and Participants:The Stop Unhealthy Alcohol Use Now (STUN) single arm, multi-site implementation study was performed at 21 primary care practices across North Carolina between February 1, 2020, and September 1, 2023. Intervention:Enrolled practices received 12 months of the practice facilitation implementation strategy, including quality improvement coaching, electronic health record support (eg, creating smart phrases or flowsheets, retrieving data), and clinician training on screening and counseling for unhealthy alcohol use. Main Outcomes and Measures:Implementation outcomes reflected adoption of evidence-based screening and counseling, including number and percentage of adult patients who were screened for unhealthy alcohol use and who received brief counseling after a positive screening result. Results:The 21 practices served 54 294 adult patients (mean [SD], 3386.2 [3418.0] per practice). Mean screening rates increased significantly, from 17.4% (95% CI, 6.0%-28.9%) per practice to 57.6% (95% CI, 29.1%-86.1%) by the end of the second quarter of practice facilitation (primary outcome; P < .001). Among screened patients, a weighted 13.9% (95% CI, 6.8%-21.1%) had positive results. The percentage of adult patients with documentation of receiving brief counseling after a positive screening result increased from 0 to 32.3% (95% CI, 13.3%-51.4%) by the end of the second quarter of practice facilitation (P < .001). After month 6, assessment of the implementation outcomes showed sustainment. There was significant variability across participating practices for screening and counseling outcomes. Conclusions and Relevance:The findings of this quality improvement study suggest that practice facilitation was associated with increased adoption of evidence-based screening and counseling for unhealthy alcohol use when provided to small and medium-sized primary care practices. This increase is projected to substantially reduce the harms of unhealthy alcohol use.

Introduction: Clinical preventive services, such as screening tests, vaccinations, behavioral counseling, or preventive medication, are offered to most people on the basis of age, sex, health behaviors, or clinical risk factors, with goals of detecting early disease, preventing future disease, or mitigating the impact of unhealthy behaviors on future health. However, many people do not receive all the recommended services for which they are eligible. Methods: The Agency for Healthcare Research and Quality identified 4 topics for gathering stakeholder input on evidence and implementation for the equitable delivery of clinical preventive services. These included technology, innovative delivery models, public health linkages, and disparities. For each topic, the authors conducted an environmental scan to identify existing programs or interventions to promote the delivery of clinical preventive services, a technical expert panel meeting, and key informant interviews. The authors synthesized input from each topic's technical expert panel and key informant interviews and used inductive reasoning to identify themes. Within each overarching theme, the authors identified subthemes supported by specific statements, examples, and illustrative quotes. Results: A total of 90 individuals participated on stakeholder panels, technical expert panels, or key informant interviews; some individuals participated in multiple roles. Across the topics, the authors identified 3 overarching themes from synthesis of the technical expert panel and key informant interview comments across topics: (1) transitioning to holistic healthcare delivery and financing models, (2) including community and patient voice in healthcare system design, and (3) leveraging technology to improve clinical preventive services delivery. Conclusions: Promoting the equitable delivery of clinical preventive services requires improving access to primary care but also expanding efforts beyond clinical settings to encompass public health and community infrastructure and engagement. Experts recommended that person-centered preventive care should empower patients to make informed decisions about clinical preventive services on the basis of their values, risks, and preferences. This more individualized approach tailored to needs and context may reduce barriers to receipt of clinical preventive services.

PROBLEM:The U.S. physician scholar workforce, currently comprising less than 1.5% of U.S. physicians, continues to decrease, threatening national status as a global biomedical research leader. Academic medical center (AMC) trends away from tenure-track physician faculty appointments toward clinical faculty appointments have contributed to this decrease, but AMCs have limited strategies to equip clinical faculty to conduct research. Infrastructure fostering clinical faculty research may establish new mechanisms for expanding physician scholar workforce and supporting academic goals of clinical faculty. This article presents one such model, the Center for Health Outcomes in Medicine Scholarship and Service (HOMES), from the Department of Internal Medicine, The Ohio State University College of Medicine. APPROACH:Established in 2019, HOMES provides research infrastructure, support, and mentorship tailored to clinical faculty needs. Multidisciplinary core faculty support research across 5 cores: clinical networks, biostatistics and secondary data, qualitative methods, mixed methods, and research ethics. HOMES services include research consultation, mentorship, microgrants, a training toolkit, and symposia. OUTCOMES:In 4 years, HOMES supported 50 faculty on 99 projects. Forty-five (90%) of these faculty have reported scholarly output, including 127 national presentations, authorship on 41 peer-reviewed articles, and 53 grant submissions. Forty HOMES-supported grant submissions have received funding, and 4 HOMES-supported physicians in training have pursued or plan to pursue AMC research careers. NEXT STEPS:HOMES has fostered scholarly productivity among AMC physicians, competitive grant applications, and research focus among physicians in training. As demand for HOMES services increases, HOMES will prioritize projects based on their innovation and research skill development potential. Academic medical centers can apply HOMES lessons through fostering clinical faculty collaboration with multidisciplinary research teams and increasing research training opportunities for residents and fellows. National expansion of funding opportunities dedicated to building biomedical research capacity and expertise among clinical faculty can facilitate sustainable scaling of HOMES-like models.

Despite substance use disorders (SUD) being a leading cause of preventable death in the US, most people who visit primary care in the US are not screened for SUD. There are multiple barriers to screening for, identifying, and managing SUD in primary care. However, there are also promising strategies available to address these barriers, including practice facilitation (PF), learning collaboratives (LC), and performance incentives (PI). This study is a 48-site cluster-randomized 2 × 2 factorial implementation trial that aims to compare the effectiveness of several strategies for implementing evidence-based screening and interventions for SUDs in primary care. Practices will be randomized to one of four implementation strategies: (1) PF only, (2) PF + LC, (3) PF + PI, or (4) all three strategies. An estimated 144 participants from 48 primary care practices will be enrolled. All participants will receive PF to guide them in making changes to implement screening for SUD, focusing on a defined change package and associated tools. PF includes quality improvement (QI) coaching, as well as electronic health record (EHR) support, training, and expert consultation. LC includes monthly virtual education sessions led by content experts to support practice improvement and innovation with didactics on key topics as well as facilitating participant interactions to share experiences. PI includes financial incentives for performance. Primary care practices will be the unit of analysis for both the primary outcome (rate of SUD screening) and secondary outcomes (rates of evidence-based interventions for SUD). Assessments will be conducted during a 12-month implementation phase and 12-month sustainment phase. This study will produce evidence regarding the comparative effectiveness of several strategies on implementation and sustainment of evidence-based screening and interventions for SUD within primary care. It will also generate knowledge about mechanisms of change in primary care settings. The results are expected to have a positive impact by providing a nuanced understanding of the incremental benefits of LC and/or PI to inform primary care practices, health systems, policymakers, and payers about optimal implementation strategies for SUD screening and evidence-based interventions. ClinicalTrials.gov NCT06524232. July 23, 2024 –registered.

BACKGROUND:In 2019, the Agency for Healthcare Research and Quality (AHRQ) funded 6 grantee teams to evaluate the effectiveness of practice facilitation (PF) as an implementation approach for improving the delivery of U.S. Preventive Services Task Force-recommended unhealthy alcohol use (UAU) services in primary care. This report characterizes practice facilitators' first-hand experiences with implementation. METHODS:We invited practice facilitators from each grantee team to participate in group interviews focused on facilitation strategies employed, facilitators and barriers encountered, adaptations made, and practice transformation observed. Interview transcripts were thematically coded using inductive and deductive methods and analyzed using immersion-crystallization. RESULTS:Seventeen practice facilitators who worked with ~300 practices participated. PF was perceived as effective in overcoming barriers to improve screening and counseling for UAU in varied settings and contexts. Practice-centered strategies that personalized practice engagement, met practices "where they are at," tailored to local context, and fostered deep cultural change were highlighted as instrumental to the multilevel changes needed to transform practice workflow around management of UAU. Facilitator quotes, strategies, and multiple facilitation resources are provided. CONCLUSIONS:Practice facilitators' collective perspectives paint a more complete picture of the processes, adaptations, and outcomes associated with this substantial practice-based research effort. PF is a versatile, flexible, and adaptable implementation approach to improve management of UAU in primary care that provides pragmatic strategies for care teams, practice leaders, researchers, and funders. Practice facilitators' collective perspectives paint a more complete picture of the processes, adaptations, and outcomes associated with this substantial practice-based research effort.

BackgroundValues clarification methods may be particularly appropriate for decision support in lung cancer screening (LCS), for which patients must consider a complex tradeoff of benefits and harms. Values clarification methods that are explicit and use theory-based methods may best support decision making.PurposeTo characterize values clarification methods in decision support tools for LCS and explore associations with behavioral and decisional outcomes.Data SourcesPubMed, Cochrane Library, CINAHL, APA PsycINFO, and Embase, supplemented with gray literature and hand searches.Study SelectionStudies evaluating patient-facing LCS decision support tools.Data ExtractionWe extracted information on study characteristics and the decision support tools evaluated in each study, including method of values clarification (explicit, implicit, or none). Study quality was evaluated using an adapted version of the SUNDAE Checklist.Data SynthesisWe identified 48 studies (10,233 participants) evaluating 32 unique decision support tools for LCS. More than 80% of tools included values clarification methods, split between explicit (n = 13) and implicit (n = 13) methods. Only 1 explicit values clarification used a theory-based method. Meta-analysis of randomized controlled trials indicated that using a decision support tool doubled the odds of receiving LCS (pooled odds ratio 1.98, 95% confidence interval 1.21-3.25, 9 studies), a pattern driven by increased uptake of screening following use of tools with explicit or no values clarification. Studies lacking values clarification were of lower quality than those with explicit or implicit methods (P = 0.04).LimitationsAlmost no tools applied theory-based methods for explicit values clarification, limiting conclusions about their impact.ConclusionsLCS decision support tools routinely incorporate values clarification methods and appear to enhance screening uptake. However, theory-based values clarification methods, which may further improve decision support quality, remain underutilized.HighlightsValues clarification is a core aspect of shared decision making. It may be especially valuable for decision making regarding lung cancer screening (LCS), as patients must weigh a complex balance of benefits and harms.This systematic review identified 48 studies assessing 32 unique decision support tools for LCS. More than 80% of these tools incorporated values clarification methods, with an equal distribution of explicit and implicit methods.Among the subset of studies using a randomized controlled trial, the use of a decision support tool doubled the odds of an individual undergoing LCS.Decision support tools designed to support shared decision making in LCS commonly incorporate values clarification methods. However, they infrequently use theory-based methods, which are increasingly thought to provide high-quality decision support.

Importance:Intimate partner violence (IPV) and caregiver abuse of older or vulnerable adults are common and cause significant morbidity. Objective:To review the evidence on screening and interventions for IPV and caregiver abuse among adults. Data Sources:PubMed, Cochrane Library, and EMBASE through December 14, 2023; ongoing literature surveillance through March 21, 2025. Study Selection:Screening test accuracy studies, randomized clinical trials (RCTs) of screening or interventions for abuse, cohort studies reporting harms. Data Extraction and Synthesis:Dual review of abstracts, full-text articles, study quality, and data extraction; narrative synthesis of results. Main Outcomes and Measures:Test accuracy; abuse exposure and associated morbidity, quality of life, and harms. Results:Thirty-five studies were included (N = 18 358). Three RCTs (n = 3759) comparing IPV screening with no screening found no significant reduction in IPV or benefit for other outcomes over 3 to 18 months and 2 (n = 935) reported no harms of screening. Nine studies (n = 9800) assessed 9 tools to detect any type of past-year IPV exposure among women; sensitivity ranged from 26% to 87% and specificity ranged from 80% to 97%. Thirteen RCTs (n = 7425) evaluated heterogeneous interventions among women with screen-detected IPV. Of these, 1 RCT (n = 239) assessing the benefit of multiple perinatal home visits found a significant reduction in IPV (standardized mean difference, -0.34 [95% CI, -0.59 to -0.08]) and 1 RCT (n = 336) assessing behavioral counseling for multiple risks (IPV, smoking, depression, tobacco exposure) found significantly fewer recurrent episodes of IPV (standardized mean difference, -0.40 [95% CI, -0.68 to -0.12]). RCTs assessing brief counseling or advocacy interventions specific to IPV found no difference between groups in rates of overall IPV. Results for other outcomes were mixed. No studies evaluated screening or interventions for caregiver abuse among older or vulnerable adults. Two studies assessed the accuracy of different screening tools to detect caregiver abuse among older adults and found mixed results. Conclusions and Relevance:Although available screening tools may reasonably identify women with past-year IPV, RCTs of IPV screening did not show reduced IPV or improvement in other outcomes. Limited evidence suggested that home visiting and behavioral counseling interventions addressing multiple risk factors may lead to reduced IPV among pregnant or postpartum women. No studies assessed screening among vulnerable adults or treatment for caregiver abuse among older or vulnerable adults.

BACKGROUND:Screening for multiple types of cancer with a single blood test is potentially transformative. PURPOSE:To assess the benefits, accuracy, and harms of screening with blood-based multicancer detection (MCD) tests in asymptomatic adults. DATA SOURCES:MEDLINE, Cochrane Library, trial registries, and relevant websites through March 2025. STUDY SELECTION:Controlled studies of MCD tests (for example, cell-free DNA) in asymptomatic populations reporting cancer detection, mortality, quality of life, and harms (psychosocial, adverse events, decrease in standard-of-care screening); uncontrolled studies for harms of diagnostic evaluation; test accuracy studies. DATA EXTRACTION:One reviewer extracted data; a second checked for accuracy; 2 reviewers independently assessed risk of bias (ROB) and strength of evidence. DATA SYNTHESIS:No controlled studies evaluated benefits of screening. Twenty studies (n = 109 177) reported accuracy for 19 MCD tests. Seven studies (5 with high ROB, 2 of unclear ROB) reported the accuracy of future cancer detection in asymptomatic persons followed for 1 year (prediagnostic performance); the rest estimated accuracy from high ROB case-control studies in clinically confirmed cancer cases and healthy, cancer-free, control participants (diagnostic performance). Across tests, sensitivity ranged from 0.095 to 0.998, specificity ranged from 0.657 to 1.0, and area under the curve (AUC) ranged from 0.52 to 1.0. Sensitivity and AUC were higher in diagnostic performance compared with prediagnostic performance studies. No other patterns in accuracy were discernible. One cohort study reported harms; however, these data were limited. LIMITATIONS:English-language studies only. Heterogeneity precluded quantitative synthesis of accuracy; estimates from the diagnostic performance studies may not be applicable to screening. CONCLUSION:No controlled studies are completed that report benefits of screening with MCD tests; evidence was judged insufficient to evaluate harms and accuracy. Accuracy varies by test and study design. FUNDING SOURCE:Agency for Healthcare Research and Quality. (PROSPERO: CRD42024570793).

PURPOSE:In January 2021, Ohio pharmacists were recognized by Medicaid as providers, became eligible to obtain Medicaid provider identification numbers, and were able to begin billing for services using evaluation and management codes. The objectives of this study were to compare outcomes before (2020) and after (2021 and 2022) pharmacist provider status was implemented in a network of primary care clinics: (1) the percent change in pharmacist-provided services that were billed and reimbursed, 2) the percent change in pharmacist-provided services that were billed as "incident-to" versus with the pharmacist as provider, and (3) the percent change in reimbursement per encounter as a result of pharmacist-provided services. METHODS:A retrospective review of all encounters and administrative claims (all payors) provided by pharmacists (7.9 full-time equivalents) within 7 primary care clinics affiliated with a large academic medical center was conducted. The data were compared year-to-year using descriptive statistics to determine the magnitude of change. RESULTS:A total of 14,416 encounters were included in the study (1,863 in 2020, 4,963 in 2021, and 7,590 in 2022). In 2020, 37.8% (705/1,863) of pharmacist encounters were billed for reimbursement. In 2021, this percentage increased to 39.1% (1,939/4,963) encounters, with a further increase in 2022 to 49.1% (3,725/7,590). Differences in the percentage of pharmacist encounters billed as incident-to versus pharmacist as provider were also evident, with 37.8% (705/1,863) of pharmacist encounters billed incident-to in 2020, as compared to 36.8% (2,796/7,590) in 2022. In this same time period, mean reimbursement for pharmacist-as-provider encounters increased by 189.5% (from $10.45 to $30.25) per encounter, and the number of pharmacist-as-provider encounters increased year over year (from 0% [0/1863] in 2020 to 1.1% [54/4,963] in 2021 and 12.3% [929/7,590] in 2022; P < 0.001). CONCLUSION:This study found an increase in the billing and reimbursement attributable to clinical pharmacists in primary care settings in Ohio after their recognition as providers.

Background: Addressing the critical public health crisis of substance use disorder (SUD), this study evaluates the accuracy of SUD treatment search tools, such as FindTreatment.gov, to connect patients with appropriate care. Methods: To ensure geographic diversity, we randomly selected one state from four distinct US regions (Arizona, Florida, Massachusetts, Ohio) and then randomly selected counties of varying sizes (one large, two medium, three small) within each state using a random number generator. Contact information for practices was extracted from the tools and validated through phone calls. The primary outcome measures were exact accuracy rate (wherein all information was accurate) and functional accuracy rate (wherein enough information was provided to facilitate care establishment). Results: A total of 697 practices from within ten SUD treatment search tools were assessed. Accuracy of the ten SUD treatment search tools varied considerably, with exact accuracy rates ranging from 9.1 % to 76.0 % (mean: 56.0 %) and functional accuracy rates from 50.0 % to 92.0 % (mean: 82.8 %). National tools exhibited higher accuracy for both exact accuracy rate (66.3 % v. 49.0 %; p = 0.2864) and functional accuracy rate (83.8 % v. 82.2 %; p = 0.9148) than state tools, while privately funded tools demonstrated higher accuracy for both exact accuracy rates (66.8 % v. 48.9 %; p = 0.2008) and functional accuracy rates (83.8 % v. 82.2 %; p = 0.9148), but none of these differences were statistically significant. Conclusions: This study found that SUD treatment search tools commonly list inaccurate information, underscoring the need for systematic improvements in data management and validation practices.

Importance Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Background: As the life expectancy of the cystic fibrosis (CF) population is lengthening with modulator therapies, diligent age-appropriate screening and preventive care are increasingly vital for long-term health and wellbeing. Methods: We performed a retrospective analysis comparing rates of receiving age- and sex-appropriate preventive services by commercially insured adult people with CF (PwCF) and adults without CF from the general population (GP) via the Truven Health MarketScan database (2012-2018). Results: We captured 25,369 adults with CF and 488,534 adults from the GP in the United States. Comparing these groups, we found that 43% versus 39% received an annual preventive visit, 28% versus 28% were screened for chlamydia, 38% versus 37% received pap smears every 3 years (21-29-year-old females), 33% versus 31% received pap smears every 5 years (30-64-year-old females), 55% versus 44% received mammograms, 23% versus 21% received colonoscopies, and 21% versus 20% received dyslipidemia screening (all screening rates expressed per 100 person-years). In age-stratified analysis, 18-27-year-old PwCF had a lower rate of annual preventive visits compared to adults in the same age group of the GP (27% versus 42%). Conclusions: We discovered a comparable-to-superior rate of preventive service utilization in adults with CF relative to the GP, except in young adulthood from 18-27 years. Our findings establish the importance of meeting the primary care needs of adults with CF and call for development of strategies to improve preventive service delivery to young adults.