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Rodriguez HP, Poon BY, Wang E, Shortell SM. Linking Practice Adoption of Patient Engagement Strategies and Relational Coordination to Patient-Reported Outcomes in Accountable Care Organizations. Milbank Q 2019; 97:692-735. [PMID: 31206824 DOI: 10.1111/1468-0009.12400] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. CONTEXT Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. METHODS We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. FINDINGS There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. CONCLUSIONS Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.
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Martsolf GR, Ashwood S, Friedberg MW, Rodriguez HP. Linking Structural Capabilities and Workplace Climate in Community Health Centers. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 55:46958018794542. [PMID: 30168364 PMCID: PMC6120169 DOI: 10.1177/0046958018794542] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many strategies to improve health care quality focus on improving the structural capabilities of primary care practices, including quality infrastructure and registry use, which are critical to managing chronic diseases. However, improving structural capabilities requires practices to expend significant resources and can be especially disruptive to community health centers (CHCs) serving high proportions of socioeconomically vulnerable patients. We explore the relationship between the structural capabilities and workplace climate in CHCs. The final sample for this analysis includes 25 CHC sites that could be matched across CHC site director surveys of structural capabilities and CHC adult primary care clinicians and staff (n = 446). To estimate the association between structural capabilities and dimensions of workplace climate, we estimated multivariate linear regression models that included the climate scales as dependent variables and the 5 structural capability scales as the main independent variables, with the 3 clinic-level and 2 staff-level covariates. More manageable clinic workload was associated with lower electronic record functionality (β = −0.47, P = .007), but positively associated with quality infrastructure (β = 0.92, P = .007). Staff relationships and quality improvement orientation were positively associated with quality infrastructure (β = 1.09, P = .006 and β = 0.87, P = .005). Manager readiness was associated with more robust quality infrastructure (β = 1.35, P = .016), but lower electronic record functionality (β = −0.48, P = .015) and less proactive patient outreach (β = −1.32, P = .025). Complex relationships between structural capabilities and workplace climate were found in CHCs. Further clarification of these complex connections may enable policy makers and practitioners to design and implement nuanced strategies to improve quality of care in CHCs.
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Phillips AZ, Rodriguez HP. Adults with diabetes residing in "food swamps" have higher hospitalization rates. Health Serv Res 2019; 54 Suppl 1:217-225. [PMID: 30613953 PMCID: PMC6341203 DOI: 10.1111/1475-6773.13102] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To examine the relationship between food swamps and hospitalization rates among adults with diabetes. Data Sources Blue Cross Blue Shield Association Community Health Management Hub® 2014, AHRQ Health Care Cost and Utilization Project state inpatient databases 2014, and HHS Area Health Resources File 2010‐2014. Study Design Cross‐sectional analysis of 784 counties across 15 states. Food swamps were measured using a ratio of fast food outlets to grocers. Multivariate linear regression estimated the association of food swamp severity and hospitalization rates. Population‐weighted models were controlled for comorbidities; Medicaid; emergency room utilization; percentage of population that is female, Black, Hispanic, and over age 65; and state fixed effects. Analyses were stratified by rural‐urban category. Principal Findings Adults with diabetes residing in more severe food swamps had higher hospitalization rates. In adjusted analyses, a one unit higher food swamp score was significantly associated with 49.79 (95 percent confidence interval (CI) = 19.28, 80.29) additional all‐cause hospitalizations and 19.12 (95 percent CI = 11.09, 27.15) additional ambulatory care‐sensitive hospitalizations per 1000 adults with diabetes. The food swamp/all‐cause hospitalization rate relationship was stronger in rural counties than urban counties. Conclusions Food swamps are significantly associated with higher hospitalization rates among adults with diabetes. Improving the local food environment may help reduce this disparity.
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Norton PT, Rodriguez HP, Shortell SM, Lewis VA. Organizational influences on healthcare system adoption and use of advanced health information technology capabilities. THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e21-e25. [PMID: 30667614 PMCID: PMC6581444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the United States. This study is the first to identify characteristics that may drive this variability among health systems. STUDY DESIGN Responses from the 2017/2018 National Survey of Healthcare Organizations and Systems were used to assess the extent to which healthcare system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of 5 advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 (58.1%) met sample inclusion criteria, and 389 (53.1%) reported consistent EHR use. METHODS Measures of adoption, resource allocation, and organizational structure were developed based on survey responses. Multivariate linear regression with control variables estimated the relationships. RESULTS Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all 5 capabilities. In adjusted analyses, EHR standardization (β = 0.76; P = .001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (β = 0.32; P = .04) was also a significant predictor. CONCLUSIONS Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced HIT adoption and use. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.
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Rodriguez HP, Friedberg MW, Vargas-Bustamante A, Chen X, Martinez AE, Roby DH. The impact of integrating medical assistants and community health workers on diabetes care management in community health centers. BMC Health Serv Res 2018; 18:875. [PMID: 30458778 PMCID: PMC6247511 DOI: 10.1186/s12913-018-3710-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 11/13/2018] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To compare the impact of implementing team-based diabetes care management involving community health workers (CHWs) vs. medical assistants (MA) in community health centers (CHCs) on diabetes care processes, intermediate outcomes, and patients' experiences of chronic care. DATA SOURCES Clinical and administrative data (n = 6111) and patient surveys (n = 698) pre-intervention and post-intervention. Surveys (n = 285) and key informant interviews (n = 48) of CHC staff assessed barriers and facilitators of implementation. STUDY DESIGN A three-arm cluster-randomized trial of CHC sites integrating MAs (n = 3) or CHWs (n = 3) for diabetes care management compared control CHC sites (n = 10). Difference-in-difference multivariate regression with exact matching of patients estimated intervention effects. PRINCIPAL FINDINGS Patients in the CHW intervention arm had improved annual glycated hemoglobin testing (18.5%, p < 0.001), while patients in the MA intervention arm had improved low-density lipoprotein cholesterol control (8.4%, p < 0.05) and reported better chronic care experiences over time (β=7.5, p < 0.001). Except for chronic care experiences (p < 0.05) for patients in the MA intervention group, difference-in-difference estimates were not statistically significant because control group patients also improved over time. Some diabetes care processes improved significantly more for control group patients than intervention group patients. Key informant interviews revealed that immediate patient care issues sometimes crowded out diabetes care management activities, especially for MAs. CONCLUSIONS Diabetes care improved in CHCs integrating CHWs and MAs onto primary care teams, but the improvements were no different than improvements observed among matched control group patients. Greater improvement using CHW and MA team-based approaches may be possible if practice leaders minimize use of these personnel to cover shortages that often arise in busy primary care practices.
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Mishra MK, Saunders CH, Rodriguez HP, Shortell SM, Fisher E, Elwyn G. How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points. BMJ Open 2018; 8:e023068. [PMID: 30385443 PMCID: PMC6252703 DOI: 10.1136/bmjopen-2018-023068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE If patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices. DESIGN Qualitative study; 103 in-depth, semi-structured interviews. PARTICIPANTS Sixty clinicians and eight managers were interviewed at two established ACOs. APPROACH We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data. KEY RESULTS Interviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches. CONCLUSIONS Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.
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Watterson JL, Rodriguez HP, Shortell SM, Aguilera A. Improved Diabetes Care Management Through a Text-Message Intervention for Low-Income Patients: Mixed-Methods Pilot Study. JMIR Diabetes 2018; 3:e15. [PMID: 30377141 PMCID: PMC6238849 DOI: 10.2196/diabetes.8645] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 03/22/2018] [Accepted: 08/14/2018] [Indexed: 12/02/2022] Open
Abstract
Background Diabetes is a major contributor to global death and disability. Text-messaging interventions hold promise for improving diabetes outcomes through better knowledge and self-management. Objective The aim of this study was to examine the implementation and impact of a diabetes text-messaging program targeted primarily for low-income Latino patients receiving care at 2 federally qualified health centers (FQHCs). Methods A mixed-methods, quasi-experimental research design was employed for this pilot study. A total of 50 Spanish or English-speaking adult patients with diabetes attending 2 FQHC sites in Los Angeles from September 2015 to February 2016 were enrolled in a 12-week, bidirectional text-messaging program. A comparison group (n=160) was constructed from unexposed, eligible patients. Demographic data and pre/post clinical indicators were compared for both the groups. Propensity score weighting was used to reduce selection bias, and over-time differences in clinical outcomes between groups were estimated using individual fixed-effects regression models. Population-averaged linear models were estimated to assess differential effects of patient engagement on each clinical indicator among the intervention participants. A sample of intervention patients (n=11) and all implementing staff (n=8) were interviewed about their experiences with the program. Qualitative data were transcribed, translated, and analyzed to identify common themes. Results The intervention group had a mean glycated hemoglobin (HbA1c) reduction of 0.4 points at follow-up, relative to the comparison group (P=.06). Patients who were more highly engaged with the program (response rate ≥median of 64.5%) experienced a 2.2 point reduction in HbA1c, relative to patients who were less engaged, controlling for demographic characteristics (P<.001). Qualitative analyses revealed that many participants felt supported, as though “someone was worrying about [their] health.” Participants also cited learning new information, setting new goals, and receiving helpful reminders. Staff and patients highlighted strategies to improve the program, including incorporating patient responses into in-person clinical care and tailoring the messages to patient knowledge. Conclusions A diabetes text-messaging program provided instrumental and emotional support for participants and may have contributed to clinically meaningful improvements in HbA1c. Patients who were more engaged demonstrated greater improvement. Program improvements, such as linkages to clinical care, hold potential for improving patient engagement and ultimately, improving clinical outcomes.
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Bustamante AV, Martinez A, Rich J, Chen X, Rodriguez HP. Comparing costs of a senior wellness care redesign in group and independent physician practices of an accountable care organization. Int J Health Plann Manage 2018; 34:241-250. [PMID: 30109902 DOI: 10.1002/hpm.2622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/07/2018] [Accepted: 07/13/2018] [Indexed: 11/07/2022] Open
Abstract
Primary care redesign for older adult patients is currently ongoing in countries with aging populations. One of the main challenges of this type of transformations is how to estimate implementation costs in different types of health care delivery organizations. This study compares start-up and incremental expenses of implementing a primary care redesign across 2 organization types: integrated group (n = 31) practices and independent practice association (IPA) sites (n = 213). Administrators involved with implementing the redesign completed a cost capture template to quantifying expenses. The potential impact of measurement error, recollection bias, and implementation models across sites and geographic regions was examined in sensitivity analyses. Marginal start-up and incremental expenses were higher for Group sites ($122-$328) compared to IPA sites ($31-$227). Group and IPA sites, however, implemented the redesign with different intensities. According to our analyses, if IPA sites implemented the redesign with the same intensity as Group sites, marginal costs would have been $5 to $13 higher for IPA sites than for Group sites. This study shows how a flexible approach to estimate the cost of a wellness care redesign is needed when the intensity of the transformation differs across 2 different types of health care organizations.
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Rodriguez HP, Starling S, Kandel Z, Weech-Maldonado R, Moss NJ, Silver L. A taxonomy of the scope and organization of local sexually transmitted disease services for policy and practice. Int J STD AIDS 2018; 29:1375-1383. [PMID: 30071798 DOI: 10.1177/0956462418787621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Local health departments (LHDs) and their organizational partners play a critical role in controlling sexually transmitted diseases (STDs) in the United States. We examine variation in the differentiation, integration, and concentration (DIC) of STD services and develop a taxonomy describing the scope and organization of local STD services. LHD STD programs (n = 115) in Alabama (AL) and California (CA) responded to surveys assessing STD services available in 2014. K-means cluster analysis identified LHD groupings based on DIC variation. Discriminant analysis validated cluster solutions. Differences in organizational partnerships and scope of STD services were compared by taxonomy category. Multivariable regression models estimated the association of the STD services organization taxonomy and five-year (2010–2014) gonorrhea incidence rates, controlling for county-level sociodemographics and resources. A three-cluster solution was identified: (1) low DIC (n = 74), (2) moderate DIC (n = 31), and (3) high DIC (n = 10). In discriminant analysis, 95% of jurisdictions were classified into the same types as originally assigned through K-means cluster analysis. High DIC jurisdictions were more likely (p < 0.001) to partner with most organizations than moderate and low DIC jurisdictions, and more likely (p < 0.001) to conduct STD needs assessment, comprehensive sex education, and targeted screening. In contrast, contact tracing, case management, and investigations were conducted similarly across jurisdictions. In adjusted analyses, there were no differences in gonorrhea incidence rates by category. Jurisdictions in CA and AL can be characterized into three distinct clusters based on the DIC of STD services. Taxonomic analyses may aid in improving the reach and effectiveness of STD services.
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Glenn BA, Crespi CM, Rodriguez HP, Nonzee NJ, Phillips SM, Sheinfeld Gorin SN, Johnson SB, Fernandez ME, Estabrooks P, Kessler R, Roby DH, Heurtin-Roberts S, Rohweder CL, Ory MG, Krist AH. Behavioral and mental health risk factor profiles among diverse primary care patients. Prev Med 2018; 111:21-27. [PMID: 29277413 PMCID: PMC5930037 DOI: 10.1016/j.ypmed.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/02/2017] [Accepted: 12/13/2017] [Indexed: 10/18/2022]
Abstract
Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.
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Kim JG, Rodriguez HP, Estlin KA, Morris CG. Impact of Longitudinal Electronic Health Record Training for Residents Preparing for Practice in Patient-Centered Medical Homes. Perm J 2018; 21:16-122. [PMID: 28746024 DOI: 10.7812/tpp/16-122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Competence in using an electronic health record (EHR) is considered a critical skill for physicians practicing in patient-centered medical homes (PCMHs), but few studies have examined the impact of EHR training for residents preparing to practice in PCMHs. This study explored the educational outcomes associated with comprehensive EHR training for family medicine residents. METHODS The PCMH EHR training consisted of case-based routine clinic visits delivered to 3 resident cohorts (N = 18). Participants completed an EHR competency self-assessment between 2011 and 2016 (N = 127), examining 6 EHR/PCMH core skills. We compared baseline characteristics for residents by low vs high exposure to EHR training. Multivariate regression estimated whether self-reported competencies improved over time and whether high PCMH EHR training exposure was associated with incremental improvement in self-reported competencies over time. RESULTS Residents completed an average of 8.2 sessions: low-exposure residents averaged 5.3 sessions (standard deviation = 1.5), and high-exposure residents averaged 9.0 sessions (standard deviation = 0.9). High-exposed residents had higher posttest scores at training completion (84.4 vs 70.7). Over time, adjusted mean scores (confidence interval) for both groups improved (p < 0.001) from 12.2 (9.6-14.8), with low-exposed residents having greater score improvement (p < 0.001) because of their much lower baseline scores. CONCLUSION Comprehensive training designed to improve EHR competencies among residents practicing in a PCMH resulted in improved assessment scores. Our findings indicate EHR training as part of resident exposure to the PCMH measurably improves self-assessed competencies, even among residents less engaged in EHR training.
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Fraze T, Lewis VA, Rodriguez HP, Fisher ES. Housing, Transportation, And Food: How ACOs Seek To Improve Population Health By Addressing Nonmedical Needs Of Patients. Health Aff (Millwood) 2018; 35:2109-2115. [PMID: 27834253 DOI: 10.1377/hlthaff.2016.0727] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations (ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
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Duru OK, Mangione CM, Rodriguez HP, Ross-Degnan D, Wharam JF, Black B, Kho A, Huguet N, Angier H, Mayer V, Siscovick D, Kraschnewski JL, Shi L, Nauman E, Gregg EW, Ali MK, Thornton P, Clauser S. Introductory Overview of the Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network: Examining the Impact of US Health Policies and Practices to Prevent Diabetes and Its Complications. Curr Diab Rep 2018; 18:8. [PMID: 29399715 PMCID: PMC8910460 DOI: 10.1007/s11892-018-0977-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Diabetes incidence is rising among vulnerable population subgroups including minorities and individuals with limited education. Many diabetes-related programs and public policies are unevaluated while others are analyzed with research designs highly susceptible to bias which can result in flawed conclusions. The Natural Experiments for Translation in Diabetes 2.0 (NEXT-D2) Network includes eight research centers and three funding agencies using rigorous methods to evaluate natural experiments in health policy and program delivery. RECENT FINDINGS NEXT-D2 research studies use quasi-experimental methods to assess three major areas as they relate to diabetes: health insurance expansion; healthcare financing and payment models; and innovations in care coordination. The studies will report on preventive processes, achievement of diabetes care goals, and incidence of complications. Some studies assess healthcare utilization while others focus on patient-reported outcomes. NEXT-D2 examines the effect of public and private policies on diabetes care and prevention at a critical time, given ongoing and rapid shifts in the US health policy landscape.
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Comfort LN, Shortell SM, Rodriguez HP, Colla CH. Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. Health Serv Res 2018; 53:2303-2323. [PMID: 29388199 DOI: 10.1111/1475-6773.12829] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N = 204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.
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Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM. The Implementation of Performance Management Systems in U.S. Physician Organizations. Med Care Res Rev 2017; 75:562-585. [PMID: 29148329 DOI: 10.1177/1077558717696993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician-hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.
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Poon BY, Shortell S, Rodriguez HP. Physician Practice Transitions to System Ownership Do Not Result in Diminished Practice Responsiveness to Patients. Health Serv Res 2017; 53:2268-2284. [PMID: 29143325 DOI: 10.1111/1475-6773.12804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the extent to which physician-to-system ownership transitions are associated with declines in practice-reported patient responsiveness (PRPR). DATA SOURCES A longitudinal cohort of practices (n = 897) from the National Survey of Large Physician Organizations/National Survey of Small- and Medium-Sized Physician Organizations (2006/08) and the National Survey of All-Size Physician Organizations (2012/13). STUDY DESIGN Multivariable regression estimated the effect of ownership on changes in PRPR, controlling for practice size, specialty composition, other practice, and market characteristics. DATA COLLECTION/EXTRACTION METHODS Data were collected from three nationally representative surveys of physician organizations consisting of 40-minute interviews with the medical director, president, or chief executive officer. PRINCIPAL FINDINGS Nine percent of organizations transitioned to system ownership. Compared to practices that were continuously physician-owned, practices that switched to system ownership did not have significantly lower PRPR at baseline but continuously system-owned practices did. Transitions to system ownership were associated with increased PRPR compared to continuously physician ownership. Increased practice size and changes in specialty composition, however, were associated with diminished PRPR. CONCLUSIONS Practices can maintain or improve strategies to address patient concerns when transferring ownership to systems with careful attention to the impact of increased size and changes in specialty composition.
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Fulton BD, Ivey SL, Rodriguez HP, Shortell SM. Countywide physician organization learning collaborative and changes in hospitalization rates. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:596-603. [PMID: 29087631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES In 2011, the California Right Care Initiative implemented a countywide physician organization learning collaborative called University of Best Practices (UBP) in San Diego County for major healthcare systems and physician organizations to share best practices in managing cardiovascular and cerebrovascular risk factors. Our objective was to examine whether UBP was associated with fewer hospitalizations for heart attacks and strokes. STUDY DESIGN A quasi-experimental design was used to compare age-adjusted adult hospitalization rates before UBP initiation (2007-2010) against rates after UBP initiation (2011-2014) in San Diego County versus the rest of California. METHODS Difference-in-differences (DID) logistic regression models were estimated using hospitalization data from the California Office of Statewide Health Planning and Development for 2007 to 2014, including 372,205 and 642,455 hospitalizations for heart attacks and strokes, respectively. RESULTS In the UBP versus pre-UBP period, the odds of adults being hospitalized for a heart attack in San Diego County decreased (odds ratio [OR], 0.84), whereas the odds stayed the same for adults in the rest of California (OR, 1.00): DID ratio of OR, 0.84 (P <.001). This relative decrease was equivalent to 2735 (or 16.5%) fewer hospitalizations, totaling $61 million (2014 dollars). No robust association was found between UBP implementation and hospitalizations for strokes. CONCLUSIONS A countywide physician organization learning collaborative was associated with fewer hospitalizations for heart attacks, but not for strokes. Healthcare systems and physician organizations should consider forming collaboratives to share best practices to manage patients' cardiovascular and cerebrovascular risk factors, which may lead to fewer hospitalizations and reduced healthcare costs.
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Miake-Lye IM, Chuang E, Rodriguez HP, Kominski GF, Yano EM, Shortell SM. Random or predictable?: Adoption patterns of chronic care management practices in physician organizations. Implement Sci 2017; 12:106. [PMID: 28836996 PMCID: PMC5571615 DOI: 10.1186/s13012-017-0639-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/16/2017] [Indexed: 11/21/2022] Open
Abstract
Background Theories, models, and frameworks used by implementation science, including Diffusion of Innovations, tend to focus on the adoption of one innovation, when often organizations may be facing multiple simultaneous adoption decisions. For instance, despite evidence that care management practices (CMPs) are helpful in managing chronic illness, there is still uneven adoption by physician organizations. This exploratory paper leverages this natural variation in uptake to describe inter-organizational patterns in adoption of CMPs and to better understand how adoption choices may be related to one another. Methods We assessed a cross section of national survey data from physician organizations reporting on the use of 20 CMPs (5 each for asthma, congestive heart failure, depression, and diabetes). Item response theory was used to explore patterns in adoption, first considering all 20 CMPs together and then by subsets according to disease focus or CMP type (e.g., registries, patient reminders). Mokken scale analysis explored whether adoption choices were linked by disease focus or CMP type and whether a consistent ordering of adoption choices was present. Results The Mokken scale for all 20 CMPs demonstrated medium scalability (H = 0.43), but no consistent ordering. Scales for subsets of CMPs sharing a disease focus had medium scalability (0.4 < H < 0.5), while subsets sharing a CMP type had strong scalability (H > 0.5). Scales for CMP type consistently ranked diabetes CMPs as most adoptable and depression CMPs as least adoptable. Within disease focus scales, patient reminders were ranked as the most adoptable CMP, while clinician feedback and patient education were ranked the least adoptable. Conclusions Patterns of adoption indicate that innovation characteristics may influence adoption. CMP dissemination efforts may be strengthened by encouraging traditionally non-adopting organizations to focus on more adoptable practices first and then describing a pathway for the adoption of subsequent CMPs. Clarifying why certain CMPs are “less adoptable” may also provide insights into how to overcome CMP adoption constraints. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0639-z) contains supplementary material, which is available to authorized users.
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Rodriguez HP, Henke RM, Bibi S, Ramsay PP, Shortell SM. The Exnovation of Chronic Care Management Processes by Physician Organizations. Milbank Q 2017; 94:626-53. [PMID: 27620686 DOI: 10.1111/1468-0009.12213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
UNLABELLED Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations. CONTEXT Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time. METHODS Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians. FINDINGS Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality. CONCLUSIONS Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.
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Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM. A Two-Step Method to Identify Positive Deviant Physician Organizations of Accountable Care Organizations with Robust Performance Management Systems. Health Serv Res 2017; 53:1851-1869. [PMID: 28384376 DOI: 10.1111/1475-6773.12693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To identify positive deviant (PD) physician organizations of Accountable Care Organizations (ACOs) with robust performance management systems (PMSYS). DATA SOURCE Third National Survey of Physician Organizations (NSPO3, n = 1,398). STUDY DESIGN Organizational and external factors from NSPO3 were analyzed. DATA COLLECTION/EXTRACTION METHODS Linear regression estimated the association of internal and contextual factors on PMSYS. Two cutpoints (75th/90th percentiles) identified PDs with the largest residuals and highest PMSYS scores. PRINCIPAL FINDINGS A total of 65 and 41 PDs were identified using 75th and 90th percentiles cutpoints, respectively. The 90th percentile more strongly differentiated PDs from non-PDs. Having a high proportion of vulnerable patients appears to constrain PMSYS development. CONCLUSIONS Our PD identification method increases the likelihood that PD organizations selected for in-depth inquiry are high-performing organizations that exceed expectations.
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Osarogiagbon RU, Rodriguez HP, Hicks D, Signore RS, Roark K, Kedia SK, Ward KD, Lathan C, Santarella S, Gould MK, Krasna MJ. Deploying Team Science Principles to Optimize Interdisciplinary Lung Cancer Care Delivery: Avoiding the Long and Winding Road to Optimal Care. J Oncol Pract 2016; 12:983-991. [DOI: 10.1200/jop.2016.013813] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The complexity of lung cancer care mandates interaction between clinicians with different skill sets and practice cultures in the routine delivery of care. Using team science principles and a case-based approach, we exemplify the need for the development of real care teams for patients with lung cancer to foster coordination among the multiple specialists and staff engaged in routine care delivery. Achieving coordinated lung cancer care is a high-priority public health challenge because of the volume of patients, lethality of disease, and well-described disparities in quality and outcomes of care. Coordinating mechanisms need to be cultivated among different types of specialist physicians and care teams, with differing technical expertise and practice cultures, who have traditionally functioned more as coactively working groups than as real teams. Coordinating mechanisms, including shared mental models, high-quality communication, mutual trust, and mutual performance monitoring, highlight the challenge of achieving well-coordinated care and illustrate how team science principles can be used to improve quality and outcomes of lung cancer care. To develop the evidence base to support coordinated lung cancer care, research comparing the effectiveness of a diverse range of multidisciplinary care team approaches and interorganizational coordinating mechanisms should be promoted.
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Tomoaia-Cotisel A, Farrell TW, Solberg LI, Berry CA, Calman NS, Cronholm PF, Donahue KE, Driscoll DL, Hauser D, McAllister JW, Mehta SN, Reid RJ, Tai-Seale M, Wise CG, Fetters MD, Holtrop JS, Rodriguez HP, Brunker CP, McGinley EL, Day RL, Scammon DL, Harrison MI, Genevro JL, Gabbay RA, Magill MK. Implementation of Care Management: An Analysis of Recent AHRQ Research. Med Care Res Rev 2016; 75:46-65. [PMID: 27789628 DOI: 10.1177/1077558716673459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Care management (CM) is a promising team-based, patient-centered approach "designed to assist patients and their support systems in managing medical conditions more effectively." As little is known about its implementation, this article describes CM implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s). Successful implementation was characterized by resource availability (both monetary and nonmonetary), identifying as well as training employees with the right technical expertise and interpersonal skills, and embedding CM within practices. Our findings facilitate future context-specific implementation of CM within medical homes. They also inform the development of medical home recognition programs that anticipate and allow for contextual variation.
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Leung LB, Vargas-Bustamante A, Martinez AE, Chen X, Rodriguez HP. Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers. Health Serv Res 2016; 53:509-531. [PMID: 27767205 DOI: 10.1111/1475-6773.12590] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference. STUDY SETTING/DATA COLLECTION Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053). STUDY DESIGN We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups. PRINCIPAL FINDINGS After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients. CONCLUSIONS Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.
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Vargas Bustamante A, Martinez A, Chen X, Rodriguez HP. Clinic Workload, the Quality of Staff Relationships and Diabetes Management in Community Health Centers Catering to Latino and Chinese Patients. J Community Health 2016; 42:481-488. [PMID: 27752860 DOI: 10.1007/s10900-016-0280-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We examine whether workplace climate-quality of staff relationships (QSR) and manageable clinic workload (MCW) are related to better patient care experiences and diabetes care in community health centers (CHCs) catering to Latino and Chinese patients. Patient experience surveys of adult patients with type 2 diabetes and workplace climate surveys of clinicians and staff from CHCs were included in an analytic sample. Comparisons of means analyses examine patient and provider characteristics. The associations of QSR, MCW and the diabetes care management were examined using regression analyses. Diabetes care process were more consistently provided in CHCs with high quality staff relations and more manageable clinic workload, but HbA1c, LDL cholesterol, and blood pressure outcomes were no different between clinics with high vs. low QSR and MCW. Focusing efforts on improvements in practice climate may lead to more consistent provision of important processes of diabetes care for these patients.
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Pimperl A, Schulte T, Mühlbacher A, Rosenmöller M, Busse R, Groene O, Rodriguez HP, Hildebrandt H. Evaluating the Impact of an Accountable Care Organization on Population Health: The Quasi-Experimental Design of the German Gesundes Kinzigtal. Popul Health Manag 2016; 20:239-248. [PMID: 27565005 DOI: 10.1089/pop.2016.0036] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
A central goal of accountable care organizations (ACOs) is to improve the health of their accountable population. No evidence currently links ACO development to improved population health. A major challenge to establishing the evidence base for the impact of ACOs on population health is the absence of a theoretically grounded, robust, operationally feasible, and meaningful research design. The authors present an evaluation study design, provide an empirical example, and discuss considerations for generating the evidence base for ACO implementation. A quasi-experimental study design using propensity score matching in combination with small-scale exact matching is implemented. Outcome indicators based on claims data were constructed and analyzed. Population health is measured by using a range of mortality indicators: mortality ratio, age at time of death, years of potential life lost/gained, and survival time. The application is assessed using longitudinal data from Gesundes Kinzigtal, one of the leading population-based ACOs in Germany. The proposed matching approach resulted in a balanced control of observable differences between the intervention (ACO) and control groups. The mortality indicators used indicate positive results. For example, 635.6 fewer years of potential life lost (2005.8 vs. 2641.4; t-test: sig. P < 0.05*) in the ACO intervention group (n = 5411) attributable to the ACO, also after controlling for a potential (indirect) immortal time bias by excluding the first half year after enrollment from the outcome measurement. This empirical example of the impact of a German ACO on population health can be extended to the evaluation of ACOs and other integrated delivery models of care.
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