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AHRQ Research Studies Date
Topics
- Adverse Drug Events (ADE) (1)
- Adverse Events (1)
- Ambulatory Care and Surgery (1)
- Brain Injury (1)
- Cancer: Lung Cancer (1)
- Cardiovascular Conditions (2)
- Care Coordination (6)
- Caregiving (2)
- Care Management (3)
- Children's Health Insurance Program (CHIP) (1)
- Children/Adolescents (7)
- Chronic Conditions (4)
- Clinician-Patient Communication (2)
- Communication (3)
- Community-Based Practice (1)
- Comparative Effectiveness (1)
- Data (2)
- Decision Making (2)
- Diabetes (1)
- Digestive Disease and Health (1)
- Education: Curriculum (1)
- Elderly (6)
- Electronic Health Records (EHRs) (1)
- Emergency Department (1)
- Emergency Medical Services (EMS) (1)
- Evidence-Based Practice (2)
- Healthcare Cost and Utilization Project (HCUP) (2)
- Healthcare Costs (1)
- Healthcare Delivery (4)
- Healthcare Utilization (2)
- Health Information Technology (HIT) (6)
- Health Services Research (HSR) (4)
- Heart Disease and Health (2)
- Home Healthcare (5)
- Hospital Discharge (14)
- Hospitalization (4)
- Hospital Readmissions (5)
- Hospitals (5)
- Imaging (1)
- Injuries and Wounds (2)
- Inpatient Care (1)
- Long-Term Care (5)
- Medical Errors (1)
- Medicare (3)
- Medication (3)
- Medication: Safety (1)
- Mortality (1)
- Neonatal Intensive Care Unit (NICU) (2)
- Newborns/Infants (2)
- Nursing (2)
- Nursing Homes (9)
- Opioids (1)
- Outcomes (2)
- Pain (1)
- Palliative Care (2)
- Patient-Centered Healthcare (5)
- Patient-Centered Outcomes Research (4)
- Patient Experience (1)
- Patient Safety (7)
- Primary Care (1)
- Provider (3)
- Provider: Nurse (2)
- Provider: Pharmacist (1)
- Quality Improvement (6)
- Quality Measures (2)
- Quality of Care (4)
- Rehabilitation (2)
- Respiratory Conditions (1)
- Risk (1)
- Social Determinants of Health (1)
- Stress (1)
- Stroke (3)
- Substance Abuse (1)
- Surgery (6)
- TeamSTEPPS (1)
- Telehealth (4)
- (-) Transitions of Care (50)
- Trauma (2)
AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
26 to 50 of 50 Research Studies DisplayedLacson R, Desai S, Landman A
Impact of a health information technology intervention on the follow-up management of pulmonary nodules.
Recommendations to improve care for patients with pulmonary nodules require follow-up management. However, transitions in care can exacerbate failures in follow-up testing and compromise patient safety. The study authors evaluated the impact of a discharge module that included follow-up recommendations for further management of pulmonary nodules on the study outcome and follow-up management of patients with pulmonary nodules within 1 year after discharge.
AHRQ-funded; HS022586.
Citation: Lacson R, Desai S, Landman A .
Impact of a health information technology intervention on the follow-up management of pulmonary nodules.
J Digit Imaging 2018 Feb;31(1):19-25. doi: 10.1007/s10278-017-9989-y..
Keywords: Cancer: Lung Cancer, Health Information Technology (HIT), Hospital Discharge, Transitions of Care
Kerstenetzky L, Birschbach MJ, Beach KF
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
The authors of this study report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to skilled nurse facilities and long term care pharmacy staff.
AHRQ-funded; HS021984.
Citation: Kerstenetzky L, Birschbach MJ, Beach KF .
Improving medication information transfer between hospitals, skilled-nursing facilities, and long-term-care pharmacies for hospital discharge transitions of care: a targeted needs assessment using the Intervention Mapping framework.
Res Social Adm Pharm 2018 Feb;14(2):138-45. doi: 10.1016/j.sapharm.2016.12.013..
Keywords: Adverse Drug Events (ADE), Hospital Discharge, Hospitals, Long-Term Care, Medical Errors, Medication, Medication: Safety, Nursing Homes, Patient Safety, Transitions of Care
Hernandez-Boussard T, Davies S, McDonald K
Interhospital facility transfers in the United States: a nationwide outcomes study.
This study identified and compared characteristics and outcomes of transfer and nontransfer patients. In-hospital adverse events were significantly higher in transfer patients compared with nontransfer patients. Study results suggest that transfer patients have inferior outcomes compared with nontransfer patients.
AHRQ-funded; HS018558.
Citation: Hernandez-Boussard T, Davies S, McDonald K .
Interhospital facility transfers in the United States: a nationwide outcomes study.
J Patient Saf 2017 Dec;13(4):187-91. doi: 10.1097/pts.0000000000000148.
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Keywords: Adverse Events, Healthcare Cost and Utilization Project (HCUP), Hospitalization, Patient Safety, Transitions of Care
Britton MC, Ouellet GM, Minges KE
Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers.
This study was conducted to identify the perspectives of sending and receiving providers regarding care transitions between the hospital and skilled nursing facilities. Four main themes emerged: increasing patient complexity, identifying an optimal care setting, rising financial pressure, and barriers to effective communication. The investigators indicated that the data highlighted hospital and SNF providers' shared concerns about patient-level risk factors and escalating costs of care.
AHRQ-funded; HS023554.
Citation: Britton MC, Ouellet GM, Minges KE .
Care transitions between hospitals and skilled nursing facilities: perspectives of sending and receiving providers.
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Keywords: Communication, Long-Term Care, Nursing Homes, Risk, Transitions of Care
Werner NE, Malkana S, Gurses AP
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Researchers aimed to highlight the importance of using a process-level view in analyzing distributed healthcare tasks through a case study analysis of medication management (MM). Their findings identified key cross-system characteristics not observable at the task-level: (1) identification of emergent properties (e.g., role ambiguity, loosely-coupled teams performing MM) and associated barriers; and (2) examination of barrier propagation across system boundaries.
AHRQ-funded; HS022916.
Citation: Werner NE, Malkana S, Gurses AP .
Toward a process-level view of distributed healthcare tasks: medication management as a case study.
Appl Ergon 2017 Nov;65:255-68. doi: 10.1016/j.apergo.2017.06.020.
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Keywords: Care Management, Elderly, Home Healthcare, Medication, Transitions of Care
Bull J, Kamal AH, Harker M
Tracking patients in community-based palliative care through the centers for Medicare & Medicaid Services Healthcare Innovation Project.
In 2014, Four Seasons Compassion for Life was awarded a Centers for Medicare & Medicaid Services Healthcare Innovation Award to expand an existing Community-Based Palliative Care (CBPC) model into additional counties and to propose a new payment approach. The goal of this article is to evaluate the tracking of point of entry into palliative care and patient transition outcomes in the model.
AHRQ-funded; HS023681.
Citation: Bull J, Kamal AH, Harker M .
Tracking patients in community-based palliative care through the centers for Medicare & Medicaid Services Healthcare Innovation Project.
J Palliat Med 2017 Nov;20(11):1231-36. doi: 10.1089/jpm.2017.0080..
Keywords: Palliative Care, Community-Based Practice, Elderly, Transitions of Care
Balaban RB, Zhang F, Vialle-Valentin CE
Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system.
The objective of this study was to determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period. The investigators concluded that a PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. The investigators suggest that their findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time peri
AHRQ-funded; HS020628.
Citation: Balaban RB, Zhang F, Vialle-Valentin CE .
Impact of a patient navigator program on hospital-based and outpatient utilization over 180 days in a safety-net health system.
J Gen Intern Med 2017 Sep;32(9):981-89. doi: 10.1007/s11606-017-4074-2..
Keywords: Care Management, Healthcare Delivery, Healthcare Utilization, Hospital Readmissions, Patient-Centered Healthcare, Transitions of Care
McHugh JP, Foster A, Mor V JP, Foster A, Mor V
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
This study used a concurrent mixed-methods approach to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal skilled nursing facilities (SNF) networks.
AHRQ-funded; HS023961.
Citation: McHugh JP, Foster A, Mor V JP, Foster A, Mor V .
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
Health Aff 2017 Sep;36(9):1591-98. doi: 10.1377/hlthaff.2017.0211..
Keywords: Care Coordination, Hospital Readmissions, Hospitals, Nursing Homes, Transitions of Care
Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M
Improving patient-centered transitional care after complex abdominal surgery.
Poor-quality transitions of care from hospital to home contribute to high rates of readmission after complex abdominal surgery. The Coordinated Transitional Care (C-TraC) program improved readmission rates in medical patients, but evidence-based surgical transitional care protocols are still lacking. This pilot study evaluated the feasibility and preliminary effectiveness of an adapted surgical C-TraC protocol. The investigators concluded that a phone-based transitional care protocol for surgical patients is feasible, with <1% refusals and 95% engagement.
patients is feasible, with <1% refusals and 95% engagement.
AHRQ-funded; HS022446.
AHRQ-funded; HS022446.
Citation: Acher AW, Campbell-Flohr SA, Brenny-Fitzpatrick M .
Improving patient-centered transitional care after complex abdominal surgery.
J Am Coll Surg 2017 Aug;225(2):259-65. doi: 10.1016/j.jamcollsurg.2017.04.008..
Keywords: Patient-Centered Healthcare, Quality of Care, Quality Improvement, Surgery, Transitions of Care
Clark B, Baron K, Tynan-McKiernan K
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
The purpose of this paper was to understand the perspectives of clinicians working at skilled nursing facilities (SNFs) regarding factors contributing to readmissions. SNF clinicians identified a broad range of factors that contributed to readmissions. The investigators suggest that addressing these factors may mitigate patients' risk of readmission from SNFs to acute care hospitals.
AHRQ-funded; HS023554.
Citation: Clark B, Baron K, Tynan-McKiernan K .
Perspectives of clinicians at skilled nursing facilities on 30-day hospital readmissions: a qualitative study.
J Hosp Med 2017 Aug;12(8):632-38. doi: 10.12788/jhm.2785..
Keywords: Hospital Readmissions, Nursing Homes, Quality Improvement, Transitions of Care
Berry J, Wilson K, Dumas H
Use of post-acute facility care in children hospitalized with acute respiratory illness.
In this retrospective analysis, the investigators assessed which children hospitalized with respiratory illness (RI) were the most likely to use post-acute facility care (PAC) for recovery. The investigators found that children with RI who were most likely to use PAC had a high prevalence of multiple chronic conditions, multiple medications, and medical technology.
AHRQ-funded; HS023092.
Citation: Berry J, Wilson K, Dumas H .
Use of post-acute facility care in children hospitalized with acute respiratory illness.
J Hosp Med 2017 Aug;12(8):626-31. doi: 10.12788/jhm.2780..
Keywords: Children/Adolescents, Hospitalization, Respiratory Conditions, Transitions of Care
Hewner S, Casucci S, Sullivan S
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. This paper describes the coordinating transitions intervention which uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach.
AHRQ-funded; HS022575.
Citation: Hewner S, Casucci S, Sullivan S .
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
eGEMS 2017 Jul 4;5(2):2. doi: 10.13063/2327-9214.1282..
Keywords: Care Coordination, Chronic Conditions, Patient-Centered Healthcare, Social Determinants of Health, Transitions of Care
Wang SY, Aldridge MD, Gross CP
End-of-life care transition patterns of Medicare beneficiaries.
The researchers characterized the patterns of transitions in care and factors associated with multiple transitions in the last 6 months of life of U.S. decedents (N = 660,132). They found that 218,731 had four or more transitions within the last 6 months of life. Women, blacks, individuals younger than 85, and individuals without dementia were more likely to have four or more transitions.
AHRQ-funded; HS023900.
Citation: Wang SY, Aldridge MD, Gross CP .
End-of-life care transition patterns of Medicare beneficiaries.
J Am Geriatr Soc 2017 Jul;65(7):1406-13. doi: 10.1111/jgs.14891.
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Keywords: Elderly, Medicare, Palliative Care, Transitions of Care
Sauser Zachrison K, Schwamm LH
Implementation of rapid treatment and interfacility transport for patients with suspected stroke by large-vessel occlusion: in one door and out the other.
This editorial discusses an article in this same issue of JAMA Neurology (McTaggart et al) that describes the results of the implementation of a standard protocol for patients with suspected emergent large-vessel occlusion (ELVO), and the protocol’s impact on both the process of care and patient outcomes. The editorial concludes that the McTaggart article challenges the medical community to develop an interdisciplinary, team-based, protocol-based approach to patients with potential ELVOs, and that work across the disciplines is needed to achieve an acceptable false-positive rate for the system.
AHRQ-funded; HS024561.
Citation: Sauser Zachrison K, Schwamm LH .
Implementation of rapid treatment and interfacility transport for patients with suspected stroke by large-vessel occlusion: in one door and out the other.
JAMA Neurol 2017 Jul;74(7):765-66. doi: 10.1001/jamaneurol.2017.0324..
Keywords: Brain Injury, Health Services Research (HSR), Healthcare Delivery, Stroke, Transitions of Care, Trauma
Jones CD, Bowles KH, Richard A
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. The authors argue that understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care.
AHRQ-funded; HS024569.
Citation: Jones CD, Bowles KH, Richard A .
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Circ Cardiovasc Qual Outcomes 2017 May;10(5). doi: 10.1161/circoutcomes.117.003676.
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Keywords: Home Healthcare, Heart Disease and Health, Transitions of Care, Care Coordination, Medicare
Fernandes-Taylor S, Gunter RL, Bennett KM
Feasibility of implementing a patient-centered postoperative wound monitoring program using smartphone images: a pilot protocol.
The researchers propose a protocol of postoperative wound monitoring using smartphone digital images. Their study will help establish the feasibility of such a program, both for patients and for the clinical care team. The feasibility trial will confirm whether patients and their caregivers can learn to use a postdischarge wound monitoring smartphone app and will assess patient and provider satisfaction.
AHRQ-funded; HS023395.
Citation: Fernandes-Taylor S, Gunter RL, Bennett KM .
Feasibility of implementing a patient-centered postoperative wound monitoring program using smartphone images: a pilot protocol.
JMIR Res Protoc 2017 Feb 22;6(2):e26. doi: 10.2196/resprot.6819.
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Keywords: Telehealth, Health Information Technology (HIT), Surgery, Injuries and Wounds, Transitions of Care
Lindquist LA, Miller RK, Saltsman WS
SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients' healthcare from skilled nursing facilities to the community.
The authors assembled a cross-cutting team of experts representing primary care physicians (PCPs), home care physicians, physicians who see patients in skilled nursing facilities (SNF physicians), skilled nursing facility medical directors, human factors engineers, transitional care researchers, geriatricians, internists, family practitioners, and three major organizations: AMDA, SGIM, and AGS. This team identified issues and developed best practices perceived as feasible for SNF physician and PCP practices to accomplish.
AHRQ-funded; HS022916.
Citation: Lindquist LA, Miller RK, Saltsman WS .
SGIM-AMDA-AGS consensus best practice recommendations for transitioning patients' healthcare from skilled nursing facilities to the community.
J Gen Intern Med 2017 Feb;32(2):199-203. doi: 10.1007/s11606-016-3850-8.
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Keywords: Quality of Care, Long-Term Care, Nursing Homes, Primary Care, Transitions of Care
Natafgi N, Zhu X, Baloh J
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
Implementation of handoff as part of TeamSTEPPS initiatives for improving shift-change communication is examined via qualitative analysis of on-site interviews and process observations in 8 critical access hospitals. Comparing implementation attributes and handoff performance across hospitals shows that the purpose of implementation did not differentiate between high and low performance, but facilitators and barriers did.
AHRQ-funded; HS018396.
Citation: Natafgi N, Zhu X, Baloh J .
Critical access hospital use of TeamSTEPPS to implement shift-change handoff communication.
J Nurs Care Qual 2017 Jan/Mar;32(1):77-86. doi: 10.1097/ncq.0000000000000203.
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Keywords: Communication, Patient Safety, Quality Improvement, TeamSTEPPS, Transitions of Care
Moyer VA, Papile LA, Eichenwald E
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
The authors tested whether a multifaceted intervention that included a health coach to assist families and an enhanced personal health record to improve the quality of information available to parents and community professionals would decrease adverse events and improve family assessment of the transition of infants born prematurely or with complex medical problems to home. They found that a multicomponent discharge intervention designed to address specific problems identified using Healthcare Failure Modes and Effects Analysis did not reduce certain adverse outcomes in the post-discharge period.
AHRQ-funded; HS017889.
Citation: Moyer VA, Papile LA, Eichenwald E .
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
BMJ Qual Saf 2014 Dec;23(12):e3. doi: 10.1136/bmjqs-2012-001726.
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Keywords: Neonatal Intensive Care Unit (NICU), Ambulatory Care and Surgery, Patient Safety, Quality Improvement, Transitions of Care
Davis AM, Brown RF, Taylor JL
Transition care for children with special health care needs.
This article examined 25 studies evaluating transition care programs for children with special health care needs moving from pediatric to adult care. The majority of studies concerned patients with diabetes or transplant patients.The authors also interviewed key informants representing clinicians who provide transition care. They found that there is no accepted way to measure transition success.
AHRQ-funded; 290201200009I
Citation: Davis AM, Brown RF, Taylor JL .
Transition care for children with special health care needs.
Pediatrics. 2014 Nov;134(5):900-8. doi: 10.1542/peds.2014-1909..
Keywords: Children/Adolescents, Transitions of Care, Chronic Conditions
Garfield CF, Lee Y, Kim HN
Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home.
The authors examined the concerns and coping mechanisms of fathers and mothers of very low-birth-weight neonatal intensive care unit (NICU) infants as they transition to home from the NICU. They found that overriding concerns included pervasive uncertainty, lingering medical concerns, and partner-related adjustment concerns that differed by gender. They concluded that many parental concerns can be addressed with improved discharge information exchanges and anticipatory guidance.
AHRQ-funded; HS020316.
Citation: Garfield CF, Lee Y, Kim HN .
Paternal and maternal concerns for their very low-birth-weight infants transitioning from the NICU to home.
J Perinat Neonatal Nurs 2014 Oct-Dec;28(4):305-12. doi: 10.1097/jpn.0000000000000021.
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Keywords: Care Coordination, Hospital Discharge, Neonatal Intensive Care Unit (NICU), Newborns/Infants, Transitions of Care
Foster NA, Elfenbein DM, Kelley W, Jr.
Comparison of helicopter versus ground transport for the interfacility transport of isolated spinal injury.
The investigators aimed to determine whether ground transport (GT) for interfacility transfer of patients with spinal injury resulted in less favorable clinical outcomes compared with helicopter aeromedical transport systems (HEMS). They found that GT for interfacility transfer of patients with spinal injury appears to be safe and suitable for patients who lack other compelling reasons for HEMS.
AHRQ-funded; HS000032.
Citation: Foster NA, Elfenbein DM, Kelley W, Jr. .
Comparison of helicopter versus ground transport for the interfacility transport of isolated spinal injury.
Spine J 2014 Jul;14(7):1147-54. doi: 10.1016/j.spinee.2013.07.478.
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Keywords: Emergency Medical Services (EMS), Transitions of Care, Injuries and Wounds
O'Toole JK, West DC, Starmer AJ
Placing faculty development front and center in a multisite educational initiative: lessons from the I-PASS Handoff study.
The authors describe their experience developing a multi-institutional faculty development program to support the I-PASS (IIPE-PRIS Accelerating Safe Signouts) Study and offer a set of generalizable strategies to guide the creation of other large-scale, multi-institutional faculty development programs. They conclude that the lessons learned inform a set of key strategies that can be applied to a broad range of similar large-scale faculty development projects in the future.
AHRQ-funded; HS019456.
Citation: O'Toole JK, West DC, Starmer AJ .
Placing faculty development front and center in a multisite educational initiative: lessons from the I-PASS Handoff study.
Acad Pediatr 2014 May-Jun;14(3):221-4. doi: 10.1016/j.acap.2014.02.013.
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Keywords: Education: Curriculum, Provider, Patient-Centered Healthcare, Transitions of Care
Black JT, Romano PS, Sadeghi B
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
The objective of this randomized controlled comparative effectiveness study was to evaluate the effectiveness of a care transition intervention that included pre-discharge education about heart failure and post-discharge telephone nurse coaching combined with home telemonitoring of weight, blood pressure, heart rate, and symptoms in reducing all-cause 180-day hospital readmissions for older adults hospitalized with heart failure.
AHRQ-funded; HS019311.
Citation: Black JT, Romano PS, Sadeghi B .
A remote monitoring and telephone nurse coaching intervention to reduce readmissions among patients with heart failure: study protocol for the Better
Trials 2014 Apr 13;15:124. doi: 10.1186/1745-6215-15-124..
Keywords: Cardiovascular Conditions, Comparative Effectiveness, Health Information Technology (HIT), Heart Disease and Health, Hospital Readmissions, Telehealth, Transitions of Care
Ritholz MD, Wolpert H, Beste M
Patient-provider relationships across the transition from pediatric to adult diabetes care: a qualitative study.
The purpose of this study was to explore perceptions that emerging adults with type 1 diabetes (T1D) have of their patient-provider relationships across the transition from pediatric to adult care. Several themes emerged from the analysis including the importance of improving provider approaches to transition. Patients recommended that pediatric providers actively promote emerging adults’ autonomy while maintaining parental support.
AHRQ-funded; HS000063.
Citation: Ritholz MD, Wolpert H, Beste M .
Patient-provider relationships across the transition from pediatric to adult diabetes care: a qualitative study.
Diabetes Educ 2014 Jan-Feb;40(1):40-7. doi: 10.1177/0145721713513177..
Keywords: Chronic Conditions, Diabetes, Patient Experience, Clinician-Patient Communication, Transitions of Care