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Factors influencing implementation of a computerized, individualized, culturally tailored lupus decision aid in lupus clinics: a qualitative semi-structured interview study

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Abstract

Objective

To identify factors that might facilitate or impede the implementation of a shared decision-making in lupus electronic tool (SMILE) in clinics by assessing perspectives of clinicians, clinic champions, and patient advocacy organization leaders.

Methods

We conducted a series of semi-structured telephone interviews (25–45 minutes) about facilitators and barriers of implementing the SMILE decision-aid tool with 23 lupus care providers (18 physicians, 5 champions), and leaders of two patient advocacy organizations. Interviews were audio recorded, transcribed, coded, and analyzed.

Results

Physicians and clinic champions were from 18 geographically diverse US clinics. The patient advocacy leaders were from the Lupus Foundation of America and the Arthritis Foundation. Most of the clinics were rheumatology specialty (94%), at university-based academic centers (72%), located in urban areas (72%), had a specialized lupus clinic (72%), were very interested (72%) in the SMILE tool and were ready to implement it (89%). Several specific factors, composed as four themes, were identified that could either facilitate or impede the implementation of the SMILE tool: (1) patient-related theme: patient recruitment and education, and the clinic visit time; (2) clinic-related theme: staff work-load and time, and physical space to view and use the SMILE tool; (3) technology-related theme: Wi-Fi connection and iPad navigation; and (4) management-related theme: influence on the clinics’ daily workflow, the need of a study champion and coordination, and leadership support.

Conclusion

Physicians, staff, and patient advocacy leaders perceived the SMILE as a promising tool to facilitate patient-provider communication and quality improvement in lupus. Identification of the patient-, clinic-, technology-, and management-related barriers to the SMILE implementation will allow its integration into busy clinical practice workflow.

Key Points

• Physicians, staff and patient advocacy leaders perceived computerized lupus decision aid to be a promising tool to facilitate shared decision-making for lupus treatment.

• Stakeholder identified patient-related, clinic-resource-related, technology-related and clinic-management related themes as barriers or facilitators to viewing computerized lupus decision aid during regular clinic visits.

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Abbreviations

SLE:

systemic lupus erythematosus

HRQOL:

health-related quality of life

SDM:

shared decision-making

PCORI:

Patient-Centered Outcome Research Institute

QA/QI:

quality improvement/quality assurance

SES:

socioeconomic status

CER:

comparative effectiveness research

SD:

standard deviation

ACR:

American College of Rheumatology

UAB:

University of Alabama at Birmingham

IDEA-WON:

individualized decision aid for diverse women with lupus nephritis

SMILE:

shared decision-making in lupus electronic tool

LFA:

Lupus Foundation of America

AF:

Arthritis Foundation

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Acknowledgments

We acknowledge Diana Florence, administrative assistant at UAB, who helped to transcribe all the interviews for analyses. We thank all the stakeholders (physicians, clinic champions and advocacy organization leaders) interviewed as a part of this initiative for their time.

Funding

JAS is supported by the resources and the use of facilities at the VA Medical Center at Birmingham, Alabama, USA. No grant funding was obtained for this project.

Author information

Authors and Affiliations

  1. Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, SHPB 580D, 1716 9th Avenue, South Birmingham, AL, 35294-1212, USA

    Haiyan Qu & Xuejun Hu

  2. Division of Clinical Immunology and Rheumatology, School of Medicine, University of Alabama at Birmingham, 510 20th Street, South Faculty Office Tower 805B, Birmingham, AL, 35294, USA

    Jasvinder A. Singh

Authors
  1. Haiyan Qu
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Corresponding author

Correspondence to Jasvinder A. Singh.

Ethics declarations

Ethical approval and consent to participate

This was a quality assurance/quality improvement (QA/QI) initiative that did not require any ethics committee approval.

Consent for publication

Not required.

Potential conflict of interest

JAS has received consultant fees from Crealta/Horizon, Medisys, Fidia, UBM LLC, Medscape, WebMD, Clinical Care options, Clearview healthcare partners, Putnam associates, Spherix, the National Institutes of Health and the American College of Rheumatology. JAS owns stock options in Amarin pharmaceuticals and Viking therapeutics. JAS is a member of the executive of OMERACT, an organization that develops outcome measures in rheumatology and receives arms-length funding from 36 companies. JAS serves on the FDA Arthritis Advisory Committee. JAS is a member of the Veterans Affairs Rheumatology Field Advisory Committee. JAS is the editor and the Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis. JAS previously served as a member of the following committees: member, the American College of Rheumatology’s (ACR) Annual Meeting Planning Committee (AMPC) and Quality of Care Committees, the Chair of the ACR Meet-the-Professor, Workshop and Study Group Subcommittee and the co-chair of the ACR Criteria and Response Criteria subcommittee. Other authors have no conflicts to declare. The funding agencies played no role in project design, collection, analysis, interpretation of data, writing of the manuscript, or in the decision to submit the paper for publication. They accept no responsibility for the contents.

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The views, presented in this article are solely the responsibility of the author(s) and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.

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Appendix. Interview questions

Appendix. Interview questions

1. What do you see as the top 3 patient barriers to the implementation of an individualized culturally- and literacy-appropriate patient self-administered decision-aid on an iPad in your clinic? Patients would view this while they are waiting to see the health care provider.

2. What do you see as the top 3 clinic or systems barriers to the implementation of a culturally- and literacy-appropriate patient self-administered lupus decision-aid on an iPad in your lupus clinic? Patients would view this while they are waiting to see the health care provider.

3. Which of these key clinic barriers do you see a clinic champion (i.e., nurse/manager) sorting out for the decision-aid implementation project?

4. Which of these key clinic barriers do you see a UAB study team sorting out for the decision-aid implementation project?

5. Are there any other critical barriers outside of these barriers that clinic nurse or UAB team can address that would make the implementation project fail?

6. How interested is the leadership in this quality initiative?

7. How ready is the practice to implement this quality initiative? Are there any competing priorities (EHR installation or leadership changes)?

8. Is your practice urban/sub-urban? Is it rheumatology-nephrology or only rheumatology? Is it like private practice or academic? How many patients could you enroll in a 1.5-2 year period?

9. What do you see as the top 3 clinic or systems facilitators in your lupus clinic to implementing a culturally- and literacy-appropriate patient self-administered lupus decision-aid?

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Qu, H., Hu, X. & Singh, J.A. Factors influencing implementation of a computerized, individualized, culturally tailored lupus decision aid in lupus clinics: a qualitative semi-structured interview study. Clin Rheumatol 38, 2793–2801 (2019). https://doi.org/10.1007/s10067-019-04643-w

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