The focus of my work is on the design, implementation and evaluation of health care delivery system interventions to improve quality of perinatal care delivery.
Specific areas of interest are:
Design and evaluation of systems-based approaches to reduce disparities in care delivery
Evaluating the impact of delivery system design on quality of care and outcomes
Implementation and evaluation of innovative strategies to promote clinical practice improvement
Changing safety culture.
Journal of perinatology : official journal of the California Perinatal Association
Safety culture, an aspect of organizational culture, that reflects work place norms toward safety, is foundational to high-quality care. Improvements in safety culture are associated with improved operational and clinical outcomes. In the neonatal intensive care unit (NICU), where fragile infants receive complex, coordinated care over prolonged time periods, it is critically important that unit norms reflect the high priority placed on safety. Changing the safety culture of the NICU involves a systematic process of measurement, identifying strengths and weaknesses, deploying targeted interventions, and learning from the results, to set the stage for an iterative process of improvement. Successful change efforts require: effective partnerships with key stakeholders including management, clinicians, staff, and families; using data to make the case for improvement; and leadership actions that motivate change, channel resources, and support active problem- solving. Sustainable change requires buy-in from NICU staff and management, resources, and long-term institutional commitment.
View details for DOI 10.1038/s41372-020-00839-0
View details for PubMedID 33024255
Unequal care: Racial/ethnic disparities in neonatal intensive care delivery.
Seminars in perinatology
Advances in neonatal intensive care have improved outcomes for preterm newborns, but significant racial/ethnic disparities persist. Neonatal disparities have their origin in a complex set of factors that include systemic racism and structural disadvantages endured by minority families, but differential quality of care in the neonatal intensive care unit (NICU) remains an important and modifiable source of disparity. NICU care has been shown to be segregated and unequal: Black and Hispanic infants are more likely to be cared for in lower quality NICUs and may receive worse care within a NICU. To eliminate disparities in care and outcomes, it is important to identify and address the mechanisms that lead to lower quality care for minority preterm infants. In this review, we identify improvements in both technical (clinical) and relational (engaging and supporting families) processes of care as critical to better outcomes for minority infants and families.
View details for DOI 10.1016/j.semperi.2021.151411
View details for PubMedID 33902931
- Introduction. Seminars in perinatology 2021: 151406
Former NICU Families Describe Gaps in Family-Centered Care.
Qualitative health research
Care and outcomes of infants admitted to neonatal intensive care vary and differences in family-centered care may contribute. The objective of this study was to understand families' experiences of neonatal care within a framework of family-centered care. We conducted focus groups and interviews with 18 family members whose infants were cared for in California neonatal intensive care units (NICUs) using a grounded theory approach and centering the accounts of families of color and/or of low socioeconomic status. Families identified the following challenges that indicated a gap in mutual trust and power sharing: conflict with or lack of knowledge about social work; staff judgment of, or unwillingness to address barriers to family presence at bedside; need for nurse continuity and meaningful relationship with nurses and inconsistent access to translation services. These unmet needs for partnership in care or support were particularly experienced by parents of color or of low socioeconomic status.
View details for DOI 10.1177/1049732320932897
View details for PubMedID 32713256
Reduction in Racial Disparities in Severe Maternal Morbidity from Hemorrhage in a Large-scale Quality Improvement Collaborative.
American journal of obstetrics and gynecology
Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. National strategies to improve maternal outcomes are increasingly focused on quality improvement collaboratives. However, the effectiveness of quality collaboratives for reducing racial disparities in maternity care is understudied.To evaluate the impact of a hemorrhage quality improvement collaborative on racial disparities in severe maternal morbidity (SMM) from hemorrhage.We conducted a cross-sectional study from 2011 to 2016 among 99 hospitals that participated in a hemorrhage quality improvement collaborative in California. The focus of the quality collaborative was to implement the national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes known to improve outcomes. This analysis included 54,311 women from the baseline period (January 2011 through December 2014) and 19,165 women from the post-intervention period (October 2015 through December 2016) with a diagnosis of obstetric hemorrhage during delivery hospitalization. We examined whether racial/ethnic-specific SMM rates in these women with obstetric hemorrhage were reduced from the baseline to the post-intervention period. In addition, we conducted Poisson Generalized Estimating Equation models to estimate relative risks (RRs) and 95% confidence intervals (CIs) for SMM comparing each racial/ethnic group to White.During the baseline period, the rate of SMM among women with hemorrhage was 22.1% (12,002/54,311) with the highest rate observed among Blacks (28.6%, 973/3,404), and the lowest among Whites (19.8%, 3,124/15,775). The overall rate fell to 18.5% (3,553/19,165) in the post-intervention period. Both Black and White mothers benefited from the intervention, but the benefit among Blacks exceeded that of Whites (9.0% vs. 2.1% absolute rate reduction). The baseline risk of SMM was 1.34 times higher among Black mothers compared to Whites (RR: 1.34, 95% CI: 1.27-1.42), and it was reduced to 1.22 (1.05-1.40) in the post-intervention period. Sociodemographic and clinical factors explained a part of the Black-White differences. After controlling for these factors, the Black-White RR was 1.22 (95% CI: 1.15-1.30) at baseline and narrowed to 1.07 (1.92-1.24) in the post-intervention period. Results were similar when excluding SMM cases with transfusion alone. After accounting for maternal risk factors, the Black-White RR for SMM excluding transfusion alone was reduced from a baseline of 1.33 (95% CI: 1.16-1.52) to 0.99 (0.76-1.29) in the post-intervention period. The most important clinical risk factor for disparate Black rates for both SMM and SMM excluding transfusion alone was cesarean delivery, potentially providing another opportunity for quality improvement.A large-scale quality improvement collaborative reduced rates of SMM due to hemorrhage in all races and reduced the performance gap between Blacks and Whites. Improving access to highly effective treatments has the potential to decrease disparities for care-sensitive acute hospital-focused morbidities.
View details for DOI 10.1016/j.ajog.2020.01.026
View details for PubMedID 31978432
- Improving Quality of Care Can Mitigate Persistent Disparities. Pediatrics 2019
Patient- and Family-Centered Care as a Dimension of Quality.
American journal of medical quality : the official journal of the American College of Medical Quality
View details for PubMedID 30501498
Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care.
Journal of perinatology : official journal of the California Perinatal Association
OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery.STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.
View details for PubMedID 29593356
- If Health Care Teams Had to Win Championships. American journal of medical quality 2017: 1062860616686684-?
Effect of clinical decision-support systems: a systematic review.
Annals of internal medicine
2012; 157 (1): 29–43
Despite increasing emphasis on the role of clinical decision-support systems (CDSSs) for improving care and reducing costs, evidence to support widespread use is lacking.To evaluate the effect of CDSSs on clinical outcomes, health care processes, workload and efficiency, patient satisfaction, cost, and provider use and implementation.MEDLINE, CINAHL, PsycINFO, and Web of Science through January 2011.Investigators independently screened reports to identify randomized trials published in English of electronic CDSSs that were implemented in clinical settings; used by providers to aid decision making at the point of care; and reported clinical, health care process, workload, relationship-centered, economic, or provider use outcomes.Investigators extracted data about study design, participant characteristics, interventions, outcomes, and quality.148 randomized, controlled trials were included. A total of 128 (86%) assessed health care process measures, 29 (20%) assessed clinical outcomes, and 22 (15%) measured costs. Both commercially and locally developed CDSSs improved health care process measures related to performing preventive services (n= 25; odds ratio [OR], 1.42 [95% CI, 1.27 to 1.58]), ordering clinical studies (n= 20; OR, 1.72 [CI, 1.47 to 2.00]), and prescribing therapies (n= 46; OR, 1.57 [CI, 1.35 to 1.82]). Few studies measured potential unintended consequences or adverse effects.Studies were heterogeneous in interventions, populations, settings, and outcomes. Publication bias and selective reporting cannot be excluded.Both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse. This review expands knowledge in the field by demonstrating the benefits of CDSSs outside of experienced academic centers.Agency for Healthcare Research and Quality.
View details for DOI 10.7326/0003-4819-157-1-201207030-00450
View details for PubMedID 22751758
Enabling health care decisionmaking through clinical decision support and knowledge management.
Evidence report/technology assessment
To catalogue study designs used to assess the clinical effectiveness of CDSSs and KMSs, to identify features that impact the success of CDSSs/KMSs, to document the impact of CDSSs/KMSs on outcomes, and to identify knowledge types that can be integrated into CDSSs/KMSs.MEDLINE(®), CINAHL(®), PsycINFO(®), and Web of Science(®).We included studies published in English from January 1976 through December 2010. After screening titles and abstracts, full-text versions of articles were reviewed by two independent reviewers. Included articles were abstracted to evidence tables by two reviewers. Meta-analyses were performed for seven domains in which sufficient studies with common outcomes were included.We identified 15,176 articles, from which 323 articles describing 311 unique studies including 160 reports on 148 randomized control trials (RCTs) were selected for inclusion. RCTs comprised 47.5 percent of the comparative studies on CDSSs/KMSs. Both commercially and locally developed CDSSs effectively improved health care process measures related to performing preventive services (n = 25; OR 1.42, 95% confidence interval [CI] 1.27 to 1.58), ordering clinical studies (n = 20; OR 1.72, 95% CI 1.47 to 2.00), and prescribing therapies (n = 46; OR 1.57, 95% CI 1.35 to 1.82). Fourteen CDSS/KMS features were assessed for correlation with success of CDSSs/KMSs across all endpoints. Meta-analyses identified six new success features: Integration with charting or order entry system. Promotion of action rather than inaction. No need for additional clinician data entry. Justification of decision support via research evidence. Local user involvement. Provision of decision support results to patients as well as providers. Three previously identified success features were confirmed: Automatic provision of decision support as part of clinician workflow. Provision of decision support at time and location of decisionmaking. Provision of a recommendation, not just an assessment. Only 29 (19.6%) RCTs assessed the impact of CDSSs on clinical outcomes, 22 (14.9%) assessed costs, and 3 assessed KMSs on any outcomes. The primary source of knowledge used in CDSSs was derived from structured care protocols.Strong evidence shows that CDSSs/KMSs are effective in improving health care process measures across diverse settings using both commercially and locally developed systems. Evidence for the effectiveness of CDSSs on clinical outcomes and costs and KMSs on any outcomes is minimal. Nine features of CDSSs/KMSs that correlate with a successful impact of clinical decision support have been newly identified or confirmed.
View details for PubMedID 23126650
View details for PubMedCentralID PMC4781172
- Evaluating the Potential Use of Modeling and Value-of-Information Analysis for Future Research Prioritization Within the Evidence-Based Practice Center Program AHRQ Methods for Effective Health Care. 2011
Metastatic breast cancer cells colonize and degrade three-dimensional osteoblastic tissue in vitro.
Clinical & experimental metastasis
2008; 25 (7): 741–52
Metastatic breast cancer cells (BCs) colonize a mineralized three-dimensional (3D) osteoblastic tissue (OT) grown from isolated pre-osteoblasts for up to 5 months in a specialized bioreactor. Sequential stages of BC interaction with OT include BC adhesion, penetration, colony formation, and OT reorganization into "Indian files" paralleling BC colonies, heretofore observed only in authentic pathological cancer tissue. BCs permeabilize OT by degrading the extra-cellular collagenous matrix (ECM) in which the osteoblasts are embedded. OT maturity (characterized by culture age and cell phenotype) profoundly affects the patterns of BC colonization. BCs rapidly form colonies on immature OT (higher cell/ECM ratio, osteoblastic phenotype) but fail to completely penetrate OT. By contrast, BCs efficiently penetrate mature OT (lower cell/ECM ratio, osteocytic phenotype) and reorganize OT. BC colonization provokes a strong osteoblast inflammatory response marked by increased expression of the pro-inflammatory cytokine IL-6. Furthermore, BCs inhibit osteoblastic bone formation by down-regulating synthesis of collagen and osteocalcin. Results strongly suggest that breast cancer disrupts the process of osteoblastic bone formation, in addition to upregulating osteoclastic bone resorption as widely reported. These observations may help explain why administration of bisphosphonates to humans with osteolytic metastases slows lesion progression by inhibiting osteoclasts but does not bring about osteoblast-mediated healing.
View details for DOI 10.1007/s10585-008-9185-z
View details for PubMedID 18543066
Extended-term culture of bone cells in a compartmentalized bioreactor.
2006; 12 (11): 3045–54
A specialized bioreactor is used to grow mineralizing, collagenous tissue up to 150 microm thick from an inoculum of isolated murine (mouse calvaria MC3T3-E1, American Type Culture Collection (ATCC) CRL-2593) or human (hFOB 1.19 ATCC CRL-11372) fetal osteoblasts over uninterrupted culture periods longer than 120 days (4 months). Proliferation and phenotypic progression of an osteogenic-cell monolayer into a tissue consisting of 6 or more cell layers of mature osteoblasts in the bioreactor was compared with cell performance in conventional tissue-culture polystyrene (TCPS) controls. Cells in the bioreactor basically matched results obtained in TCPS over a 15-day culture interval, but loss of insoluble extracellular matrix and an approximate doubling of apoptosis rates in TCPS after 30 days indicated that progressive instability of cultures maintained in TCPS with periodic refeeding but without subculture. In contrast, stable cultures were maintained in the bioreactor for more than 120 days, suggesting that extended-term tissue maintenance is feasible with little or no special technique. Transmission electron microscopy ultramorphology of tissue derived from hFOB 1.19 recovered from the bioreactor after only 15 days of culture showed evidence of osteocytic-like processes and gap junctions between cells like those observed in vivo, in addition to elaboration of the usual osteoblastic markers such as alkaline phosphatase activity and mineralization (alizarin red). Thus, the bioreactor design based on the principle of simultaneous growth and dialysis was shown to create an extraordinarily stable peri-cellular environment that better simulates the in vivo condition than conventional tissue culture. The bioreactor shows promise as a tool for the in vitro study of osteogenesis and osteopathology.
View details for DOI 10.1089/ten.2006.12.3045
View details for PubMedID 17518620