As health care resources quickly and heavily shifted toward COVID-19 testing and management in 2020, the primary care system struggled to meet the needs of Americans across the country, with access to many services delayed or diminished.
In April 2020, nearly 90% of primary care providers reported they were severely limiting regular check-ups and had growing concerns about unmonitored chronic conditions, reduced preventive care, and patient access to telehealth services.
The switch from in-person care to fully virtual communication introduced new barriers and consequences for two groups in particular: patients with chronic conditions and underserved communities. Technological limitations — such as lack of access to the internet, a computer or a smartphone — and struggles with digital and electronic health literacy have worsened pre-existing disparities in the management and prevention of chronic diseases.
“The clinics are the ones that need the tools to be able to reduce disparities,” says Olayinka Shiyanbola, associate professor in the Social and Administrative Sciences Division at the University of Wisconsin–Madison School of Pharmacy.
“When we do work around equity, we tend to focus on individuals, but I think we need to step up and say it’s time for clinics to meet equitable standards for the patients they serve,” she says.
An expert in health equity research, Shiyanbola is the co-investigator of a new project, funded by a pilot award from the UW Institute for Clinical and Translational Research, helping clinics develop strategies for delivering equitable care and prevent additional increases in health disparities.
The project, led by principal investigator Edmond Ramly from the UW School of Medicine and Public Health (SMPH), is engaging patients and health care team members to co-design a configurable, evidence-based tool to help clinics map local barriers to effective solutions and strategies for the prevention and management of chronic diseases. Using a systems engineering approach, the evidence-based tool will help clinics and patients address health inequities in their community.
Building the tool
Ramly, a health systems engineer with expertise in implementation science and human factors, Shiyanbola, and colleagues from medicine, nursing, and engineering — including Professor Elizabeth Cox and Associate Professor Kirsten Rindfleisch from SMPH — set out with a lofty goal: to build an effective, intuitive tool that can identify and provide recommendations for specific local barriers impacting primary care practice, while being generalizable enough to be used for a variety of clinic applications.
The tool is being constructed upon two frameworks widely established in the field of implementation science — the Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change (ERIC).
CFIR provides a guide for systematically assessing 39 known potential barriers to implementation while ERIC is a published compilation of 76 evidence-based implementation strategy terms and uses. The pilot study builds on a CFIR-ERIC mapping, which provides a list of ERIC-based strategies to consider based on CFIR-based barriers, prioritized by percentage of expert agreement.
The pilot study is bringing in a variety of local stakeholders at the individual, clinic, and organizational levels to participate in co-designing and building the tool. Ramly and Shiyanbola, and other faculty on the team will be using their input to personalize the CFIR-ERIC framework with information specific to primary care and sources of inequities in access to care.
“Essentially, we’re using both of these frameworks as the building blocks of our tool,” says Ramly. “In our co-design sessions with different stakeholder groups — patients, clinic staff and health system leaders — we are identifying barriers and strategy ideas in their own terms to design, modify and refine those evidence-based building blocks to make a tool that is practical, relevant, useful, and usable.”
For example, if a clinic seeks to improve their process for receiving patient feedback on quality of team-based care, the CFIR-ERIC matching tool will recommend the clinic implement tools for quality monitoring, use data experts, develop quality monitoring systems, and organize clinician team meetings.
“Tailoring the strategies requires several steps,” says Shiyanbola. “With the help of our stakeholders, we will be able to assess and understand determinants within the local context and adapt known intervention strategies to fit a clinic’s needs.”
The stakeholder sessions will focus on primary care in general but will specifically take up the rapid telehealth expansion and what new barriers that poses.
“For example, we’re hearing about barriers related to cardiovascular disease management, as well as diabetes, behavioral health, depression and a variety of other chronic conditions,” says Ramly. “We’re looking at this broader type of need — which is patients who need frequent contact with the health care team, frequent follow up, and often coordinated team-based care.”
When engaging organizational stakeholders at UW Health, UW Family Medicine, UW General Internal Medicine, and local federally qualified health centers, the researchers are focused on cataloging the barriers contributing to inequitable health outcomes in Madison.
“While it is always important to have a patient-centered perspective, having the clinics as stakeholders is equally as important when designing this tool,” says Shiyanbola. “Talking to diverse collaborators and allowing for everybody’s voices to be heard introduces different angles and in the long run, will help us develop a better tool.”
Development of the tool, which will function like an online menu, will continue for the next year. Then, it will be pilot tested in four local clinics.
“We want to take our time and make sure the tool has gone through a very rigorous process and is well-developed and tested before it is implemented in clinics beyond Madison,” says Shiyanbola. “Having a well-designed tool will hopefully help a lot of clinics map barriers to primary care in their locality and stop the increases in disparities.”
As an experienced health disparities and equity researcher, Shiyanbola brings a critical health equity lens to this research.
“In my perspective, every researcher should always apply an equity lens to all work they do,” says Shiyanbola. “It may seem like a lot of responsibility to put on every researcher, but it’s so important to make sure your work will not worsen disparities.”
Shiyanbola has been conducting behavioral research in underserved communities in Wisconsin for years, particularly around chronic disease self-management. She was invited by Ramly to join the pilot project as an academic collaborator to ensure the work advances equity and maintains a patient-centered perspective.
“Shiyanbola’s depth and breadth of experience with health care disparities and engaging patients and stakeholders in designing interventions that meet their needs is of great value to this research,” says Ramly. He says he also brought her on the team for her experience with mixed methods research, medication adherence, and patient perceptions of their role in taking part in their own care.
Shiyanbola says she was excited to join the project and be involved in stakeholder engagement — which, according to Shiyanbola, is an integral part of any research that is frequently underutilized.