External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases

The influence of psychological characteristics on managers efficiency within medical institutions during the COVID-19 pandemic

This article examines the theoretical and practical aspects of the activity of medical managers, the social and psychological climate within teams, and interpersonal relations. The goal of the study was to investigate the interpersonal interaction styles and intragroup relations between team members and managers, as well as to determine the impact of managers' psycho-emotional characteristics on their effectiveness during the COVID-19 pandemic. A total of 158 medical workers participated in the study, which was conducted in 2021 using a self-developed questionnaire. The expert evaluation method and standardized psychodiagnostic methods were used. We identified negative factors that affected the management of medical institutions during the pandemic, such as deficiencies in material and economic support, low levels of managerial competence, violation of collegiality and fairness principles during duties and rewards distribution, and deficiencies in manager recruitment. The most psychologically challenging aspects of managing or working in a medical facility during a pandemic include excessive emotional tension and stress, high levels of responsibility, lack of management experience and/or competence in crisis conditions, physical overload, work outside of working hours, and lack of adequate rest. A mini-personality profile of the effective manager of medical institutions in pandemic conditions was developed. One of the psychological regularities of a manager's performance identified is the presence of self-regulative skills in negative emotional states, pronounced activity and energy, mobility, and a strong desire for action.

Decentralized Patient-Centric Report and Medical Image Management System Based on Blockchain Technology and the Inter-Planetary File System

Several academicians have been actively contributing to establishing a practical solution to storing and distributing medical images and test reports in the research domain of health care in recent years. Current procedures mainly rely on cloud-assisted centralized data centers, which raise maintenance expenditure, necessitate a large amount of storage space, and raise privacy concerns when exchanging data across a network. As a result, it is critically essential to provide a framework that allows for the efficient exchange and storage of large amounts of medical data in a secure setting. In this research, we describe a unique proof-of-concept architecture for a distributed patient-centric test report and image management (PCRIM) system that aims to facilitate patient privacy and control without the need for a centralized infrastructure. We used an Ethereum blockchain and a distributed file system technology called the Inter-Planetary File System in this system (IPFS). Then, to secure a distributed and trustworthy access control policy, we designed an Ethereum smart contract termed the patient-centric access control protocol. The IPFS allows for the decentralized storage of medical metadata, such as images, with worldwide accessibility. We demonstrate how the PCRIM system design enables hospitals, patients, and image requestors to obtain patient-centric data in a distributed and secure manner. Finally, we tested the proposed framework in the Windows environment by deploying a smart contract prototype on an Ethereum TESTNET blockchain. The findings of the study indicate that the proposed strategy is both efficient and practicable.

Adoption of Patient Engagement Strategies by Physician Practices in the United States

BACKGROUND

Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally.

METHODS

We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region.

RESULTS

We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies.

CONCLUSIONS

This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.

Physician Practices With Robust Capabilities Spend Less On Medicare Beneficiaries Than More Limited Practices

No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.

A Socio-Analytical Approach to the Integration of Drones into Health Care Systems

The integration of drones into health care as a supplement to existing logistics methods may generate a need for cooperation and involvement across multiple resource areas. It is currently not well understood whether such integrations would merely represent a technical implementation or if they would cause more significant changes to laboratory services. By choosing socio-technical theory as the theoretical lens, this paper intends to harvest knowledge from the literature on various organizational concepts and examine possible synergies between such theories to determine optimal strategies for introducing the use of drones in a health care context. Our particular interest is to examine whether the insights generated from the multi-level perspective (MLP) may have the potential to create dynamic spin-offs related to the organizational transitions associated with the implementation of drones in health services. We built our study on a scoping literature review of topics associated with the MLP and socio-technical studies from differing arenas, supplemented with studies harvested on a broader basis. The scoping review is based on 25 articles that were selected for analysis. As a way of organizing the literature, the niche, regime, and landscape levels of the MLP are translated to the corresponding health care-related terms, i.e., clinic, institution, and health care system. Furthermore, subcategories emerged inductively during the process of analysis. The MLP provides essential knowledge regarding the context for innovation and how the interaction between the different levels can accelerate the diffusion of innovations. Several authors have put both ethical topics and public acceptance into a socio-technological perspective. Although a socio-technical approach is not needed to operate drones, it may help in the long run to invest in a culture that is open to innovation and change.

Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis

BACKGROUND

Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care.

METHODS

We performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use.

RESULTS

About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics.

CONCLUSIONS

Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.

Are health systems redesigning how health care is delivered?

OBJECTIVE

To explore why and how health systems are engaging in care delivery redesign (CDR)-defined as the variety of tools and organizational change processes health systems use to pursue the Triple Aim.

STUDY SETTING

A purposive sample of 24 health systems across 4 states as part of the Agency for Healthcare Research and Quality's Comparative Health System Performance Initiative.

STUDY DESIGN

An exploratory qualitative study design to gain an "on the ground" understanding of health systems' motivations for, and approaches to, CDR, with the goals of identifying key dimensions of CDR, and gauging the depth of change that is possible based on the particular approaches to redesign care being adopted by the health systems.

DATA COLLECTION

Semi-structured telephone interviews with health system executives and physician organization leaders from 24 health systems (n = 162).

PRINCIPAL FINDINGS

We identify and define 13 CDR activities and find that the health systems' efforts are varied in terms of both the combination of activities they are engaging in and the depth of innovation within each activity. Health system executives who report strong internal motivation for their CDR efforts describe more confidence in their approach to CDR than those who report strong external motivation. Health system leaders face uncertainty when implementing CDR due to a limited evidence base and because of the slower than expected pace of payment change.

CONCLUSIONS

The ability to validly and reliably measure CDR activities-particularly across varying organizational contexts and markets-is currently limited but is key to better understanding CDR's impact on intended outcomes, which is important for guiding both health system decision making and policy making.

The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians

Policy Points One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs. At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low-income populations, but not exposure to value-based payment. Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity.

CONTEXT

One of the most important possibilities of value-based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value-based payment will encourage health care providers to innovate to address upstream social risks.

METHODS

We used the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices' participation in value-based payment models; and (3) measures of practices' capacity for innovation. We used multivariate regression models to examine predictors of social risk screening.

FINDINGS

On average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices' overall exposure to value-based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices' capacity for innovation.

CONCLUSIONS

Our results indicate that implementation of social risk screening-an initial step in enhancing awareness of social needs in health care-is not associated with overall exposure to value-based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.

A Provincial Survey of the Contemporary Management of Autosomal Dominant Polycystic Kidney Disease

Background:

Recent years have witnessed an encouraging expansion of knowledge and management tools in the care of patients with autosomal dominant polycystic kidney disease (ADPKD), including measurement of total kidney volume as a biomarker of disease progression, stringent blood pressure targets to slow cyst growth, and targeted treatments such as tolvaptan.

Objectives:

We sought to evaluate clinicians’ familiarity with, and usage of, novel evidence-based management tools for ADPKD.

Design:

On-line survey.

Setting:

British Columbia, Canada.

Participants:

Nephrologists in academic and community practice (excluding clinicians who practice exclusively in transplantation).

Measurements:

Participants answered multiple-choice questions in 6 domains: sources of information, self-identified needs for optimal care delivery, prognostication, imaging tests, blood pressure targets, and use of tolvaptan.

Methods:

An online survey was developed and disseminated via email to 65 nephrologists engaged in current clinical practice in British Columbia.

Results:

A total of 29 nephrologists (45%) completed the questionnaire. The most popular source of information was the primary literature (83% of respondents). While 86% of respondents reported assessing the risk of disease progression before the onset of kidney function decline, most were using traditional metrics such as blood pressure and proteinuria rather than validated prediction tools such as the Mayo Classification. Although 90% of respondents obtained additional imaging after diagnosis in some or all of their ADPKD patients, only 1 in 5 reported being confident in their ability to interpret kidney size. The recommended blood pressure (BP) target of <110/75 mmHg was sought by 17% of respondents. All respondents reported being familiar with the literature regarding tolvaptan; however, only half were confident in their ability to identify suitable patients for treatment. The top 3 needs identified by clinicians were better access to medications (69%), clear management protocols (66%), and easier access to imaging tests (59%).

Limitations:

Funding mechanisms for tolvaptan can vary; therefore, clinicians’ experience with the drug may not be generalizable. Although the response rate was acceptable, the survey is nonetheless subject to responder bias.

Conclusion:

This survey indicates that there is substantial variability in the usage of, and familiarity with, evidence-based ADPKD management tools among contemporary nephrologists, contributing to incomplete translation of evidence into clinical practice. Providing greater access to tolvaptan or imaging tests is unlikely to improve patient care without enhancing knowledge translation and education.

Trial Registration:

Not applicable as this was a survey.

Effects of an Electronic Software "Prompt" With Health Care Professional Training on Cardiovascular and Renal Complications in a Multiethnic Population With Type 2 Diabetes and Microalbuminuria (the GP-Prompt Study): Results of a Pragmatic Cluster-Randomized Trial

OBJECTIVE

Tight, targeted control of modifiable cardiovascular risk factors can reduce cardiovascular complications and mortality in individuals with type 2 diabetes mellitus (T2DM) and microalbuminuria. The effects of using an electronic "prompt" with a treatment algorithm to support a treat-to-target approach has not been tested in primary care.

RESEARCH DESIGN AND METHODS

A multicenter, cluster-randomized trial was conducted among primary care practices across Leicestershire, U.K. The primary outcome was the proportion of individuals achieving systolic and diastolic blood pressure (<130 and <80 mmHg, respectively) and total cholesterol (<3.5 mmol/L) targets at 24 months. Secondary outcomes included proportion of individuals with HbA_1c <58 mmol/mol (<7.5%), changes in prescribing, change in the albumin-to-creatinine ratio, major adverse cardiovascular events, cardiovascular mortality, and coding accuracy.

RESULTS

A total of 2,721 individuals from 22 practices, mean age 63 years, 41% female, and 62% from black and minority ethnic groups completed 2 years of follow-up. There were no significant differences in the proportion of individuals achieving the composite primary outcome, although the proportion of individuals achieving the prespecified outcome of total cholesterol <4.0 mmol/L (odds ratio 1.24; 95% CI 1.05-1.47; P = 0.01) increased with intensive intervention compared with control. Coding for microalbuminuria increased relative to control (odds ratio 2.05; 95% CI 1.29-3.25; P < 0.01).

CONCLUSIONS

Greater improvements in composite cardiovascular risk factor control with this intervention compared with standard care were not achieved in this cohort of high-risk individuals with T2DM. However, improvements in lipid profile and coding can benefit patients with diabetes to alter the high risk of atherosclerotic cardiovascular events. Future studies should consider comprehensive strategies, including patient education and health care professional engagement, in the management of T2DM.

The CMS State Innovation Models Initiative and Improved Health Information Technology and Care Management Capabilities of Physician Practices

The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.

Evaluation of a Health Information Technology-Enabled Panel Management Platform to Improve Anticoagulation Control in a Low-Income Patient Population: Protocol for a Quasi-Experimental Design

BACKGROUND

Warfarin is one of the most commonly prescribed medications in the United States, and it causes a significant proportion of adverse drug events. Patients taking warfarin fall outside of the recommended therapeutic range 30% of the time, largely because of inadequate laboratory monitoring and dose adjustment. This leads to an increased risk of blood clots or bleeding events. We propose a comparative effectiveness study to examine whether a technology-enabled anticoagulation management program can improve long-term clinical outcomes compared with usual care.

OBJECTIVE

Our proposed intervention is the implementation of an electronic dashboard (integrated into a preexisting electronic health record) and standardized workflow to track patients' laboratory results, identify patients requiring follow-up, and facilitate the use of a validated nomogram for dose adjustment. The primary outcome of this study is the time in therapeutic range (TTR) at 6 months post intervention (a validated metric of anticoagulation quality among patients receiving warfarin).

METHODS

We will employ a pre-post quasi-experimental design with a nonequivalent usual-care comparison site and a difference-in-differences approach to compare the effectiveness of a technology-enabled anticoagulation management program compared with usual care at a large university-affiliated safety-net clinic.

RESULTS

We used a commercially available health information technology (HIT) platform to host a registry of patients on warfarin therapy and create the electronic dashboard for panel management. We developed the intervention with, and for, frontline clinician users, using principles of human-centered design. This study is funded until September 2020 and is approved by the University of California, San Francisco Institutional Review Board until June 22, 2020. We completed data collection in September 2019 and expect to complete our proposed analyses by February 2020.

CONCLUSIONS

We anticipate that the intervention will increase TTR among patients taking warfarin and that the use of this HIT platform will facilitate tracking and monitoring of patients on warfarin, which could enable outreach to those overdue for visits or laboratory monitoring. We will use these findings to iteratively improve the platform in preparation for a larger, multiple-site, pragmatic clinical trial. If successful, our study will demonstrate the integration of HIT platforms into existing electronic health records to improve patient care in real-world clinical settings.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/13835.

Has the clinical governance development agenda stalled? Perceptions of New Zealand medical professionals in 2012 and 2017

Clinical governance is a key policy and organisational foundation for health care quality improvement. This study sought to measure progress with clinical governance development from the perspective of practicing medical professionals in the New Zealand public health system. A short fixed-response survey, with questions derived from a government policy statement, was sent in 2012 and 2017 to all registered medical professionals in ongoing employment in New Zealand's public health system. Respondents, therefore, worked across New Zealand's 20 District Health Boards (DHBs), which own and manage public hospital and health care services. The survey sought to gauge medical professionals' perspectives around performance on, and implementation of, key clinical governance components. The overall performance in clinical governance development declined or stalled between the two survey periods across eight out of 10 key survey questions. There were improvements on two questions relating to respondent familiarity with clinical governance concepts, and to management support for clinical leadership development, but no change in areas such as having a structure to support clinical governance, or working in partnership with management. Limited government and DHB policy attention to clinical governance may well have contributed to stalled development across the New Zealand health system. If so, this finding has lessons for other countries and health systems in which there has been varying government support for the clinical governance agenda with ramifications around expectations for clinical leadership on, and involvement in, quality improvement.

Strategies for Delivering Value-Based Care: Do Care Management Practices Improve Hospital Performance?

EXECUTIVE SUMMARY

Value-based payment has the potential to rein in the volume incentive inherent in fee-for-service payment by holding providers accountable for the quality of patient care they deliver. Success under the new payment structure will depend on how effectively key organizational reforms are embraced by providers in the implementation of quality improvement processes for care delivery. This study examined the relationship between implementation of care management processes (CMPs, the specific tactics that enable the practice of value-based care) and hospital performance under value-based payment. Using the American Hospital Association's Survey of Care Systems and Payment and the Centers for Medicare & Medicaid Services' Hospital Compare, we estimated the relationship between hospital implementation of CMPs and performance as it relates to spending, patient satisfaction, readmission reduction, value-based purchasing, and clinical care outcomes. We found that hospitals increased implementation of CMPs from 2013 to 2014, which has led to modest changes in performance. We concluded that care coordination is associated with greater improvements in hospital performance. However, the long-term effects of resulting changes in care delivery may differ from the short-term effects. Thus, study findings underscore the importance of continued evaluation of care management practice as a strategy for optimizing delivery of high-quality, efficient patient care.

How the delivery of HIV care in Canada aligns with the Chronic Care Model: A qualitative study

With the advent of continuous antiretroviral therapy, HIV has become a complex chronic, rather than acute, condition. The Chronic Care Model (CCM) provides an integrated approach to the delivery of care for people with chronic conditions that could therefore be applied to the delivery of care for people living with HIV. Our objective was to assess the alignment of HIV care settings with the CCM. We conducted a mixed methods study to explore structures, organization and care processes of Canadian HIV care settings. The quantitative results of phase one are published elsewhere. For phase two, we conducted semi-structured interviews with key informants from 12 HIV care settings across Canada. Irrespective of composition of the care setting or its location, HIV care in Canada is well aligned with several components of the CCM, most prominently in the areas of linkage to community resources and delivery system design with inter-professional team-based care. We propose the need for improvements in the availability of electronic clinical information systems and self-management support services to support better care delivery and health outcomes among people living with HIV in Canada.

Horizontal and vertical integration's role in meaningful use attestation over time

OBJECTIVE

To compare rates of attestation and attrition from the MU program by independent, horizontally integrated, and vertically integrated physicians and to assess whether MU created pressure for independent physicians to join integrated organizations.

DATA SOURCE/STUDY SETTING

Secondary Data from SK&A and Medicare MU Files, 2011-2016. Office-based physicians in the 50 United States and District of Columbia.

STUDY DESIGN

We compared attestation rates among physicians that remained independent or integrated throughout the study period. We then assessed the association between changing integration and MU attestation in multivariate regression models.

PRINCIPAL FINDINGS

Our sample included 291 234 physicians. Forty nine percent of physicians that remained independent throughout the period attested to MU at least once during the program, compared with 70 percent of physicians that remained horizontally or vertically integrated physicians. Only approximately 50 percent of independent physicians that attested between 2011 and 2013 attested in 2015, representing significantly more attrition than we observed among integrated physicians. In multivariate regression models, physicians that joined these organizations were more likely to have attested to MU prior to integrating and this difference increased following integration.

CONCLUSIONS

These findings point toward a growing digital divide between physicians who remain independent and integrated physicians that may have been exacerbated by the MU program. Targeted public policy, such as new regional extension centers, should be considered to address this disparity.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

BACKGROUND

Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed.

METHODS

This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes.

CONCLUSION

We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.

Organizational influences on healthcare system adoption and use of advanced health information technology capabilities

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.

Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care?

Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.

Clinical Inertia in Type 2 Diabetes Patients in Primary Health Care Clinics in Central Bosnia

BACKGROUND The goal of this research was to determine the frequency of clinical inertia of general practice physicians in the region of Central Bosnia in healthcare for type 2 diabetes patients, to analyze characteristics of patients and physicians, as well as glucose regulation during clinical inertia, and, on the basis of these indicators, give recommendations for reducing clinical inertia. MATERIAL AND METHODS This study included 29 doctors, family physicians, or general practitioners, who collected data in a total sample of 541 type 2 diabetes mellitus patients from July to November 2017. The research was conducted using 2 questionnaires. The glucose concentration in plasma and the percentage of glycosylated hemoglobin (HbA1c) were determined. Concertation of cholesterol, triglycerides, AST, and ALT were also measured. After the collection, new data were processed and the degree of clinical inertia was determined. RESULTS Levels of HbA1c ranged from 4.3% to 13.0%, and 38.4% of all patients had HbA1c level higher than 7.5%, while 8.3% of them had HbA1c level 9.0% or higher. Clinical inertia in our research was 12.6% out of all patients and 48.2% were referred to a specialist by their doctor. CONCLUSIONS For better regulation of glycemia and reduction of clinical inertia with type 2 diabetes patients, more specialized training is needed for selected physicians. Strengthening of primary healthcare and encouraging doctors to perform procedures can contribute to better outcomes of treatment, lower clinical inertia, and better education of patients.

Stakeholder Views on Solutions to Improve Health System Performance

Context

Significant reforms are needed to improve healthcare system performance in Quebec. Even though the characteristics of high-performing healthcare systems are well-known, Quebec's reforms have not succeeded in implementing many critical elements. Converging evidence from political science models suggests stakeholders' preferences are central in determining policy content, adoption, and implementation.

Objective

To analyze whether doctors', nurses', pharmacists' and health administrators' preferences could explain the observed inability to implement known characteristics of high-performing healthcare systems.

Design

A questionnaire on various propositions identified in the scientific literature was sent to 2,491 potential respondents.

Results

Overall response rate was 37%. There was considerable consensus on identified solutions to improve the healthcare system. Resistance was observed in two major areas: information systems and changes directly affecting doctors' practice. The groups' positions cannot explain the inability to implement important characteristics of high-performing systems. The findings raise new questions on the actual sources of resistance.

Spending per Medicare Beneficiary Is Higher in Hospital-Owned Small- and Medium-Sized Physician Practices

OBJECTIVE

To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care.

DATA SOURCE/STUDY SETTING/DATA COLLECTION

Survey data for 1,045 primary care-based practices of 1-19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices.

STUDY DESIGN

We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending).

PRINCIPAL FINDINGS

Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices.

CONCLUSIONS

Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.

The role of health information technology in advancing care management and coordination in accountable care organizations

BACKGROUND

To be successful, accountable care organizations (ACOs) must effectively manage patient care. Health information technology (HIT) can support care delivery by providing various degrees of coordination. Few studies have examined the role of HIT functionalities or the role of different levels of coordination enabled by HIT on care management processes.

PURPOSES

We examine HIT functionalities in ACOs, categorized by the level of coordination they enable in terms of information and work flow, to determine which specific HIT functionalities and levels of coordination are most strongly associated with care management processes.

METHODOLOGY/APPROACH

Retrospective cross-sectional analysis was done using 2012 data from the National Survey of Accountable Care Organizations. HIT functionalities are categorized into coordination levels: information capture, the lowest level, which coordinates through standardization; information provision, which supports unidirectional activities; and information exchange, which reflects the highest level of coordination allowing for bidirectional exchange. The Care Management Process index (CMP index) includes 13 questions about the extent to which care is planned, monitored, and supported by providers and patients. Multiple regressions adjusting for organizational and ACO contractual factors are used to assess relationships between HIT functionalities and the CMP index.

FINDINGS

HIT functionality coordinating the most complex interdependences (information exchange) was associated with a 0.41 standard deviation change in the CMP index (β = .41, p < .001), but the associations for information capture (β = -.01, p = .97) and information provision (β = .15, p = .48) functionalities were not significant.

IMPLICATIONS

The current study has shed some light on the relationship between HIT and care management processes by specifying the coordination roles that HIT may play and, in particular, the importance of information exchange functionalities. Although these represent early findings, further research can help policy makers and clinical leaders understand how to prioritize HIT development given resource constraints.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

BACKGROUND

Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm.

OBJECTIVE

To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices.

METHODS

An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies.

RESULTS

Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect.

CONCLUSION

The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Optimizing the Care Coordinator Role in Primary Care: A Qualitative Case Study

BACKGROUND

Care coordinators (CCs) are increasingly employed in primary care as a means to improve health care quality, but little research examines the process by which CCs are integrated into practices. This case study provides an in-depth examination of this process and efforts to optimize the role.

METHODS

Two CCs' work was observed and assessed, and attempts were made to optimize the role using workflow modeling and "Plan-Do-Study-Act" cycles. Rolling qualitative analyses of field notes from key informant interviews and team meetings were conducted using iterative cycles of "immersion/crystallization" to identify emerging themes.

RESULTS

Expected roles of CCs included case management of high-risk patients, transitions of care, and population management. Case management was the least difficult to implement; transition management required more effort; and population management met with individual and institutional obstacles and was difficult to address.

CONCLUSIONS

The process by which CCs are integrated into primary care is not well understood and will require more attention to optimally use this role to improve health care quality. Understanding aspects of CCs' roles that are the least and most difficult to integrate may provide a starting place for developing best practices for implementation of this emerging role.

Does paying service providers by results improve recovery outcomes for drug misusers in treatment in England?

AIM

To compare drug recovery outcomes in commissioning areas included in a 'payment by results' scheme with all other areas.

DESIGN

Observational and data linkage study of the National Drug Treatment Monitoring System, Office for National Statistics mortality database and Police National Computer criminal records, for 2 years before and after introduction of the scheme. Pre-post controlled comparison compared outcomes in participating versus non-participating areas following adjustment for drug use, functioning and drug treatment status.

SETTING

Drug services in England providing publicly funded, structured treatment.

PARTICIPANTS

Adults in treatment (between 2010 and 2014): 154 175 (10 716 in participating areas, 143 459 non-participating) treatment journeys in the 2 years before and 148 941 (10 012 participating, 138 929 non-participating) after the introduction of the scheme.

INTERVENTION

Scheme participation, with payment to treatment providers based on patient outcomes versus all other areas.

MEASUREMENTS

Rate of treatment initiation; waiting time (> or < 3 weeks); treatment completion; and re-presentation; substance use; injecting; housing status; fatal overdose; and acquisitive crime.

FINDINGS

In participating areas, there were relative decreases in rates of: treatment initiation [difference-in-differences odds ratio (DID OR) = 0.17, 95% confidence interval (CI) = 0.14, 0.21]; treatment completion (DID OR = 0.60, 95% CI = 0.53, 0.67); and treatment completion without re-presentation (DID OR = 0.63, 95% CI = 0.52, 0.77) compared with non-participating areas. Within treatment, relative abstinence (DID OR = 1.50, 95% CI = 1.30, 1.72) and non-injecting (DID OR = 1.32, 95% CI = 1.10, 1.59) rates were improved in participating areas. No significant changes in mortality, recorded crime or housing status were associated with the scheme.

CONCLUSION

Drug addiction recovery services in England that are commissioned on a payment-by-results basis tend to have lower rates of treatment initiation and completion but higher rates of in-treatment abstinence and non-injecting than other services.

The changing roles of community nurses: the case of health plan nurses in Israel

BACKGROUND

In Israel, approximately one-third of the country's nurses work in community settings - primarily as salaried employees in Israel's four non-profit health plans. Many health system leaders believe that the roles of health plan nurses have changed significantly in recent years due to a mix of universal developments (such as population aging and academization of the profession) and Israel-specific changes (such as the introduction of extensive quality monitoring in primary care).

OBJECTIVES

The main objectives of the study were to identify recent changes in the roles of health plan nurses and their current areas of activity. It also explored the experience of front-line nurses with regard to autonomy, work satisfaction, and barriers to further role development.

METHODS

The study integrated interviews and surveys of nurses and other professionals conducted across 4 years. Data generated from earlier study components were used to guide questions and focus for later components. In 2013, in-depth interviews were held with 55 senior nursing and medical professionals supplemented by interviews in mid-2017 with the head nurses in the four health plans. In addition, a national survey was conducted in 2014-5 among a representative sample of 1019 community nurses who work for the health plans and who are engaged in direct patient care. Six hundred ninety-two nurses responded to the survey, yielding a response rate of 69%. The survey sample consisted of an equal number of nurses from each health plan, and the observations were weighted accordingly.

FINDINGS

Senior professionals identified general themes associated with a shift in nursing roles, including a transition from reactive to initiated work, increased specialization, and a shifting of tasks from hospitals to community settings. They identified the current main areas of activity in the health plans as being: routine care, chronic care, health promotion, quality monitoring and improvement, specialized care (such as wound care), and home care. In the survey of front-line nurses, 38% of the nurses identified "caring for chronically ill patients" as their main area of activity aside from routine care; 30% did so regarding "health promotion", and 26% did so regarding "a specific area of specialization" e.g., diabetes, wound care or women's health). In response to a separate question, 77% reported "great" or "very great" involvement in quality measurement programs. Four out of five front-line nurses were satisfied with their work to a great or very great extent, and approximately three out of four of them (73%) felt that they had autonomy at work to a great or very great extent. About half of the nurses take into account, to a great or very great extent, the financial concerns of the health plans that employ them. A large majority of the nurses (85%) indicated that the nature of their work had changed substantially in recent years, with an increase in autonomy noted as one of the key changes. Perceived barriers to further role development include attitudes on the part of some physicians and nurses, an insufficient number of dedicated nursing positions, and insufficiently attractive wage levels.

CONCLUSIONS

The findings, gathered over 4 years, indicate alignment between universal and Israel-specific trends in health care and the evolving roles of nurses in Israel's health plans. The findings provide support for ongoing efforts in the health plans to give nurses more authority and responsibility in the management of chronically ill patients, a more central role in health promotion efforts, more advanced training - both inter-professional and nurse-specific, and more opportunity to focus on the roles and tasks that require nursing professionals.

The Implementation of Performance Management Systems in U.S. Physician Organizations

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.

Do different approaches to clinical governance development and implementation make a difference? Findings from Ireland and New Zealand

Purpose

Clinical governance (CG) is an important foundation for a high-performing health care system, with many countries supporting its development. CG policy may be developed and implemented nationally, or devolved to a local level, with implications for the overall approach to implementation and policy uptake. However, it is not known whether one of these two approaches is more effective. The purpose of this paper is to probe this question. Its setting is Ireland and New Zealand, two broadly comparable countries with similar CG policies. Ireland’s was nationally led, while New Zealand’s was devolved to local districts. This leads to the question of whether these different approaches to implementation make a difference.

Design/methodology/approach

Data from surveys of health professionals in both countries were used to compare performance with CG development.

Findings

The study showed that Ireland’s approach produced a slightly better performance, raising questions about the merits of devolving responsibility for policy implementation to the local level.

Research limitations/implications

The Irish and New Zealand surveys both had lower-than-desirable response rates, which is not uncommon for studies of health professionals such as this. The low response rates mean the findings may be subject to selection bias.

Originality/value

Despite the importance of the question of whether a national or local approach to policy implementation is more effective, few studies specifically focus on this, meaning that this study provides a new contribution to the topic.

Designing and Implementing an Electronic Patient Registry to Improve Warfarin Monitoring in the Ambulatory Setting

BACKGROUND

Warfarin requires individualized dosing and monitoring in the ambulatory setting for protection against thromboembolic disease. Yet in multiple settings, patients spend upwards of 30% of time outside the therapeutic range, subjecting them to an increased risk of adverse events. At an urban, publicly funded clinic, the electronic health record (EHR) would not support integration with extant warfarin management software, which led to the creation and implementation of an electronic patient registry and a complementary team-based work flow to provide real-time health-system-level data for warfarin patients.

METHODS

Creation of the registry, which began in August 2014, entailed use of an existing platform, which could interface with the outpatient EHR. The registry was designed to help ensure regular testing and monitoring of patients while enabling identification of patients and subpopulations with suboptimal management. The work flow used for the clinic's warfarin patients was also redesigned. An assessment indicated that the registry identified 341 (96%) of 357 patients actively seen in the clinic.

RESULTS

For the cohort of the 357 patients in the registry, the no-show rate decreased from 31% (preimplementation, August 2014-December 2014) to 21% (postimplementation, January 2015-November 2015). The ratio of visits to no-shows increased from 2.3 to 4.0 visits.

CONCLUSION

Design and implementation of an electronic registry in conjunction with a complementary work flow established an active tracking system that improved treatment monitoring for patients on anticoagulation therapy. Registry creation also facilitated assessment of the quality of care and laid the groundwork for ongoing evaluation and quality improvement efforts.

The Exnovation of Chronic Care Management Processes by Physician Organizations

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.

Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities

PURPOSE OF REVIEW

Population care approaches for diabetes have the potential to improve the quality of care and decrease diabetes-related mortality and morbidity. Population care strategies are particularly relevant as accountable care organizations (ACOs), patient-centered medical homes (PCMH), and integrated delivery systems are increasingly focused on managing chronic disease care at the health system level. This review outlines the key elements of population care approaches for diabetes in the current health care environment.

RECENT FINDINGS

Population care approaches proactively identify diabetes patients through disease registries and electronic health record data and utilize multidisciplinary care teams, personalized provider feedback, and decision support tools to target and care for patients at risk for poor outcomes. Existing evidence suggests that these strategies can improve care outcomes and potentially ameliorate existing race/ethnic disparities in health care. However, such strategies may be less effective for patients who are disengaged from the health care system. As population care for diabetes continues to evolve, future initiatives should consider ways to tailor population care to meet individual patient needs, while leveraging improvements in clinical information systems and care integration to optimally manage and prevent diabetes in the future.

Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.

Patterns of computed tomography surveillance in survivors of colorectal cancer at Veterans Health Administration facilities

BACKGROUND

Annual computed tomography (CT) scans are a component of the current standard of care for the posttreatment surveillance of survivors of colorectal cancer (CRC) after curative-intent resection. The authors conducted a retrospective study with the primary aim of assessing patient, physician, and organizational characteristics associated with the receipt of CT surveillance among veterans.

METHODS

The Department of Veterans Affairs Central Cancer Registry was used to identify patients diagnosed with AJCC collaborative stage I to III CRC between 2001 and 2009. Patient sociodemographic and clinical (ie, CRC stage and comorbidity) characteristics, provider specialty, and organizational characteristics were measured. Hierarchical multivariable logistic regression models were used to assess the association between patient, provider, and organizational characteristics on receipt of 1) consistently guideline-concordant care (at least 1 CT every 12 months for both of the first 2 years of CRC surveillance) versus no CT receipt and 2) potential overuse (>1 CT every 12 months during the first 2 years of CRC surveillance) of CRC surveillance using CT. The authors also analyzed the impact of the 2005 American Society of Clinical Oncology update in CRC surveillance guidelines on care received over time.

RESULTS

For 2263 survivors of stage II/III CRC who were diagnosed after 2005, 19.4% of patients received no surveillance CT, whereas potential overuse occurred in both surveillance years for 14.9% of patients. Guideline-concordant care was associated with younger age, higher stage of disease (stage III vs stage II), and geographic region. In adjusted analyses, younger age and higher stage of disease (stage III vs stage II) were found to be associated with overuse. There was no significant difference in the annual rate of CT scanning noted across time periods (year ≤ 2005 vs year > 2005).

CONCLUSIONS

Among a minority of veteran survivors of CRC, both underuse and potential overuse of CT surveillance were present. Patient factors, but no provider or organizational characteristics, were found to be significantly associated with patterns of care. The 2005 change in American Society of Clinical Oncology guidelines did not appear to have an impact on rates of surveillance CT. Cancer 2017;123:2338-2351. © 2017 American Cancer Society.

Patient Portal as a Tool for Enhancing Patient Experience and Improving Quality of Care in Primary Care Practices

INTRODUCTION

This study assessed whether patient portals influence patients' ability for self-management, improve their perception of health state, improve their experience with primary care practices, and reduce healthcare utilization.

METHODS

Patients participating in a nurse-led care coordination program received personalized training to use the portal to communicate with the care team. Data analysis included pre-post comparison of self-efficacy (CDSES), health state (EQVAS), functional status (PROMIS®), experience with the provider/practice (CG-CAHPS), and healthcare utilization (admissions and ED visits).

RESULTS

A total of 94 patients were enrolled, and 92 (Intent to Treat) were followed up for 7 months to assess their experience, and for 12 months to assess healthcare utilization. Seventy four (mean age 60+13 years) used the portal (Users). Comparison between baseline and 7-month follow-up showed no statistically significant improvements in self-efficacy, perception of health state or experience with the primary care practice. Only functional status improved significantly. ED visits/1000 patients were reduced by 26% and 21% in the Intent to Treat and Users groups, respectively. Hospital admissions/1000 patients were reduced by 46% in the Intent to Treat group and by 38% in the Users group.

DISCUSSION

For patients in care coordination, having access to patient portals may improve access to providers and health data that lead to improvements in patients' functional status and reduce high-cost healthcare utilization, but it does not seem to improve self-efficacy, perception of health state, or experience with primary care practices.

CONCLUSION

In this study, the use of patient portals improved functional status and reduced high-cost healthcare utilization in patients with chronic conditions.

Managing chronic illness: physician practices increased the use of care management and medical home processes

The effective management of patients with chronic illnesses is critical to bending the curve of health care spending in the United States and is a crucial test for health care reform. In this article we used data from three national surveys of physician practices between 2006 and 2013 to determine the extent to which practices of all sizes have increased their use of evidence-based care management processes associated with patient-centered medical homes for patients with asthma, congestive heart failure, depression, and diabetes. We found relatively large increases over time in the overall use of these processes for small and medium-size practices as well as for large practices. However, the large practices used fewer than half of the recommended processes, on average. We also identified the individual processes whose use increased the most and show that greater use of care management processes is positively associated with public reporting of patient experience and clinical quality and with pay-for-performance.

Reductions in diabetic cardiovascular risk by community primary care providers

OBJECTIVE

To evaluate a community-based, not-for-profit medical group's effectiveness with diabetic management while using an electronic medical record and financial incentives.

DESIGN

Descriptive retrospective study over 2 years with published reference standards.

METHODS

There were 5,316 diabetic patients in the medical group (MG) compared with 5,069 diabetic patients reported in the literature (CT). The main outcome measures included serum hemoglobin A1C (HbA1C), total (TC), low density lipoprotein (LDL-C) and high density lipoprotein (HDL-C) cholesterol, and clinic measures of systolic (SBP) and diastolic blood pressure. We determined a mean 10-year composite multivariable cardiovascular risk score based upon these parameters.

RESULTS

The mean MG serum HbA1C (7.10+/-0.02; 8.18+/-0.23%), TC (193.2+/-0.64; 218.3+/-6.09 mg/dl), LDL-C (109.2+/-0.52; 137.8+/-4.24 mg/dl), and SBP (132.8+/-0.25; 141.6+/-2.36 mmHg) were below those for the CT (p<0.001). The MG mean overall coronary heart disease risk of 14.9+/-1.4% over 10 years was below that for the CT group of 22.7+/-2.3%, representing a 34.7+/-4.4% reduction (p<0.0002). The electronic medical record and the use of a financial award may have contributed to these results.

CONCLUSION

Improvement of cardiovascular risk variables can be achieved in the primary care setting. Electronic tools and incentives may facilitate this improvement.

Using feedback to change primary care physician behavior

Recognizing the gap between high-quality care and the care actually provided, health care providers across the country are under increasing institutional and payer pressures to move toward more high-quality care. This pressure is often leveraged through data feedback on provider performance; however, feedback has been shown to have only a variable effect on provider behavior. This study examines the cognitive behavioral factors that influence providers to participate in feedback interventions, and how feedback interventions should be implemented to encourage more provider engagement and participation.

Increasing Value: A Research Agenda for Addressing the Managerial and Organizational Challenges Facing Health Care Delivery in the United States

There is growing consensus that the U.S. health care system is not producing value relative to the resources invested. Unwarranted variation exists in quality and outcomes of care and underutilization of both evidence-based medicine and evidence-management practices. To address these issues, this article calls for a broad-based social science approach focused on obtaining a greater understanding of change at the individual, group, organizational, and environmental levels as they influence each other. Specific examples and questions for research are suggested with regard to the redesign of care systems, enhancing learning and transferring knowledge, and creating effective financial incentives. The specific measurement, analysis, and study design issues involved in under-taking such a research agenda are discussed.

Characteristics Associated with Patient-Centered Medical Home Capability in Health Centers: A Cross-Sectional Analysis

BACKGROUND

The patient-centered medical home (PCMH) model is being implemented in health centers (HCs) that provide comprehensive primary care to vulnerable populations.

OBJECTIVE

To identify characteristics associated with HCs' PCMH capability.

DESIGN

Cross-sectional analysis of a national dataset of Federally Qualified Health Centers (FQHCs) in 2009. Data for PCMH capability, HC, patient, neighborhood, and regional characteristics were combined from multiple sources.

PARTICIPANTS

A total of 706 (70 %) of 1014 FQHCs from the Health Resources and Services Administration Community Health Center Program, representing all 50 states and the District of Columbia.

MAIN MEASURES

PCMH capability was scored via the Commonwealth Fund National Survey of FQHCs through the Safety Net Medical Home Scale (0 [worst] to 100 [best]). HC, patient, neighborhood, and regional characteristics (all analyzed at the HC level) were measured from the Commonwealth survey, Uniform Data System, American Community Survey, American Medical Association physician data, and National Academy for State Health Policy data.

KEY RESULTS

Independent correlates of high PCMH capability included having an electronic health record (EHR) (11.7-point [95 % confidence interval, CI 10.2-13.3]), more types of financial performance incentives (0.7-point [95 % CI 0.2-1.1] higher total score per one additional type, maximum possible = 10), more types of hospital-HC affiliations (1.6-point [95 % CI 1.1-2.1] higher total score per one additional type, maximum possible = 6), and location in certain US census divisions. Among HCs with an EHR, location in a state with state-supported PCMH initiatives and PCMH payments was associated with high PCMH capability (2.8-point, 95 % CI 0.2-5.5). Other characteristics had small effect size based on the measure unit (e.g. 0.04-point [95 % CI 0-0.08] lower total score per one percentage point more minority patients), but the effects could be practically large at the extremes.

CONCLUSIONS

EHR adoption likely played a role in HCs' improvement in PCMH capability. Factors that appear to hold promise for supporting PCMH capability include a greater number of types of financial performance incentives, more types of hospital-HC affiliations, and state-level support and payment for PCMH activities.

The Adoption of Innovations by Provider Organizations in Health Care

Innovations in health care account for some of the most dramatic improvements in population health outcomes in the developed world as well as for a nontrivial proportion of growth in expenditures. Provider organizations are the adopters of many of these innovations, and understanding the factors that inhibit or facilitate their diffusion to and possible disengagement from these organizations is important in addressing cost, quality, and access issues. Given the importance of these issues, the purpose of this article is to (1) create a comprehensive census of studies examining the adoption of and disengagement from innovations in health care provider organizations; (2) organize these studies into an inductively derived classification scheme; (3) assess the studies' strengths and weaknesses; and (4) reflect on the implications of our review for future research.

Improving Clinical Practice Using a Novel Engagement Approach: Measurement, Benchmarking and Feedback, A Longitudinal Study

BACKGROUND

Poor clinical outcomes are caused by multiple factors such as disease progression, patient behavior, and structural elements of care. One other important factor that affects outcome is the quality of care delivered by a provider at the bedside. Guidelines and pathways have been developed with the promise of advancing evidence-based practice. Yet, these alone have shown mixed results or fallen short in increasing adherence to quality of care. Thus, effective, novel tools are required for sustainable practice change and raising the quality of care.

METHODS

The study focused on benchmarking and measuring variation and improving care quality for common types of breast cancer at four sites across the United States, using a set of 12 Clinical Performance and Value(®) (CPV(®)) vignettes per site. The vignettes simulated online cases that replicate a typical visit by a patient as the tool to engage breast cancer providers and to identify and assess variation in adherence to evidence-based practice guidelines and pathways.

RESULTS

Following multiple rounds of CPV measurement, benchmarking and feedback, we found that scores had increased significantly between the baseline round and the final round (P < 0.001) overall and for all domains. By round 4 of the study, the overall score increased by 14% (P < 0.001), and the diagnosis with treatment plan domain had an increase of 12% (P < 0.001) versus baseline.

CONCLUSION

We found that serially engaging breast cancer providers with a validated clinical practice engagement and measurement tool, the CPVs, markedly increased quality scores and adherence to clinical guidelines in the simulated patients. CPVs were able to measure differences in clinical skill improvement and detect how fast improvements were made.

Do Health Systems Have Consistent Performance Across Locations and Is Consistency Associated With Higher Performance?

This study addresses whether health systems have consistent diabetes care performance across their ambulatory clinics and whether increasing consistency is associated with improvements in clinic performance. Study data included 2007 to 2013 diabetes care intermediate outcome measures for 661 ambulatory clinics in Minnesota and bordering states. Health systems provided more consistent performance, as measured by the standard deviation of performance for clinics in a system, relative to propensity score-matched proxy systems created for comparison purposes. No evidence was found that improvements in consistency were associated with higher clinic performance. The combination of high performance and consistent care is likely to enhance a health system's brand reputation, allowing it to better mitigate the financial risks of consumers seeking care outside the organization. These results suggest that larger health systems are most likely to deliver the combination of consistent and high-performance care. Future research should explore the mechanisms that drive consistent care within health systems.

Evaluating the Quality of Sexual Health Care Provided to Adolescents in Medicaid Managed Care: A Comparison of Two Data Sources

This study compares 2 data sources to evaluate the quality of sexual health care provided to adolescents in Medicaid managed care: (a) Medicaid encounter data and (b) medical record data. Data from 1998 for 1112 adolescent enrollees came from 3 Seattle-area managed care organizations (MCOs): a group model health maintenance organization, an independent practice association, and a clinic network. Quality of care was tracked by estimating within-MCO chlamydia testing rates for sexually active female enrollees. Rates varied dramatically depending on which data source was used. Logistic regression models indicated substantially less difference between MCOs when analysis was based on data from the 2 sources combined than when based on either data source alone. Study results did not support the use of Medicaid encounter data as a sole data source for evaluating quality of adolescent sexual health care, despite the cost savings this would represent. However, encounter data, used as an adjunct to medical record review, may increase the reliability of quality evaluations.

Using multi-stakeholder alliances to accelerate the adoption of health information technology by physician practices

BACKGROUND

Multi-stakeholder alliances - groups of payers, purchasers, providers, and consumers that work together to address local health goals - are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities.

METHODS

Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 - March 2009 and January 2012-November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients' online access to their medical records.

RESULTS

Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients' online access to medical records between AF4Q and non-AF4Q communities.

CONCLUSION

By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients' online access to medical records.

IMPLICATIONS

Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Preventive Care Quality of Medicare Accountable Care Organizations: Associations of Organizational Characteristics With Performance

BACKGROUND

Accountable Care Organizations (ACOs) are a delivery and payment model aiming to coordinate care, control costs, and improve quality. Medicare ACOs are responsible for 8 measures of preventive care quality.

OBJECTIVES

To create composite measures of preventive care quality and examine associations of ACO characteristics with performance.

DESIGN

This is a cross-sectional study of Medicare Shared Savings Program and Pioneer participants. We linked quality performance to descriptive data from the National Survey of ACOs. We created composite measures using exploratory factor analysis, and used regression to assess associations with organizational characteristics.

RESULTS

Of 252 eligible ACOs, 246 reported on preventive care quality, 177 of which completed the survey (response rate=72%). In their first year, ACOs lagged behind PPO performance on the majority of comparable measures. We identified 2 underlying factors among 8 measures and created composites for each: disease prevention, driven by vaccines and cancer screenings, and wellness screening, driven by annual health screenings. Participation in the Advanced Payment Model, having fewer specialists, and having more Medicare ACO beneficiaries per primary care provider were associated with significantly better performance on both composites. Better performance on disease prevention was also associated with inclusion of a hospital, greater electronic health record capabilities, a larger primary care workforce, and fewer minority beneficiaries.

CONCLUSIONS

ACO preventive care quality performance is related to provider composition and benefitted by upfront investment. Vaccine and cancer screening quality performance is more dependent on organizational structure and characteristics than performance on annual wellness screenings, likely due to greater complexity in eligibility determination and service administration.

Comparing and improving chronic illness primary care in Sweden and the USA

Purpose - The purpose of this paper is to identify opportunities for improving primary care services for people with chronic illnesses by comparing how Sweden and US services use evidence-based practices (EBPs), including digital health technologies (DHTs). Design/methodology/approach - A national primary healthcare center (PHCC) heads surveys in 2012-2013 carried out in both countries in 2006. Findings - There are large variations between the two countries. The largest, regarding effective DHT use in primary care centers, were that few Swedish primary healthcare compared to US heads reported having reminders or prompts at the point of care (38 percent Sweden vs 84 percent USA), despite Sweden's established electronic medical records (EMR). Swedish heads also reported 30 percent fewer centers receiving laboratory results (67 percent Sweden vs 97 percent USA). Regarding following other EBPs, 70 percent of Swedish center heads reported their physicians had easy access to diabetic patient lists compared to 14 percent in the USA. Most Swedish PHCC heads (96 percent) said they offered same day appointment compared to 36 percent in equivalent US practices. Practical implications - There are opportunities for improvement based on significant differences in effective practices between the countries, which demonstrates to primary care leaders that their peers elsewhere potentially provide better care for people with chronic illnesses. Some improvements are under primary care center control and can be made quickly. There is evidence that people with chronic illnesses in these two countries are suffering unnecessarily owing to primary care staff failing to provide proven EBP, which would better meet patient needs. Public finance has been invested in DHT, which are not being used to their full potential. Originality/value - The study shows the gaps between current and potential proven effective EBPs for services to patients with chronic conditions. Findings suggest possible explanations for differences and practical improvements by comparing the two countries. Many enhancements are low cost and the proportionate reduction in suffering and costs they bring is high.

Measuring Healthcare Providers' Performances Within Managed Competition Using Multidimensional Quality and Cost Indicators

BACKGROUND AND OBJECTIVES

The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition.

DATA AND METHODS

We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers.

RESULTS AND CONCLUSION

There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition.