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Schwenka N, Donovan A, Franck L, Coan C, McAdam-Marx C, Shin E. Patient-centered medical home pharmacists' impact on composite quality care measures for patients with uncontrolled type 2 diabetes. J Am Pharm Assoc (2003) 2023; 63:1545-1552.e4. [PMID: 37301508 DOI: 10.1016/j.japh.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/02/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Patients with uncontrolled diabetes are at risk for developing complications. Many health care systems have implemented multidisciplinary care models including pharmacists to help achieve quality care measures to reduce complications. OBJECTIVE This study aimed to evaluate whether patients with uncontrolled type 2 diabetes mellitus (T2D) seen at patient-centered medical home (PCMH) clinics affiliated with an academic medical center are more likely to meet a composite of diabetes quality care measures with a pharmacist on their care team than usual care patients without a pharmacist on their care team. METHODS This is a cross-sectional study. The setting included PCMH primary care clinics affiliated with an academic medical center from January 2017 to December 2020. Included were adults aged 18 to 75 years with a diagnosis of T2D, hemoglobin A1C (A1C) more than 9%, and established with a PCMH provider. The intervention is inclusion of PCMH pharmacist on the patient's care team for management of T2D per a collaborative practice agreement. The main outcome measures included A1C ≤9% per last recorded value during observation period, a composite A1C ≤9% and completion of yearly laboratory tests, and a composite A1C ≤9%, completion of yearly laboratory tests, and statin prescription for adults aged 40-75 years. RESULTS Identified were 1807 patients in the usual care cohort with mean baseline A1C of 10.7% and 207 patients in the pharmacist cohort with mean baseline A1C of 11.1%. The pharmacist cohort was more likely to have an A1C of ≤9% at the end of the observation period (70.1% vs. 45.4%; P < 0.001), a composite of measures met (28.5% vs. 16.8%; P < 0.001), and a composite of measures met for patients aged 40-75 years (27.2% vs. 13.7%; P < 0.001). CONCLUSION Pharmacist involvement in the multidisciplinary management of uncontrolled T2D is associated with a higher attainment of a composite of quality care measures at the population health level.
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Sum G, Kadir MM, Ho SH, Yoong J, Chay J, Wong CH. Cost analysis of a Patient-Centred Medical Home for community-dwelling older adults with complex needs in Singapore. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2022; 51:553-566. [PMID: 36189700 DOI: 10.47102/annals-acadmedsg.2022165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION The Patient-Centred Medical Home (PCMH) demonstration in Singapore, launched in November 2016, aimed to deliver integrated and patient-centred care for patients with biopsychosocial needs. Implementation was based on principles of comprehensiveness, coordinated care and shared decision-making. METHOD We conducted a prospective single-arm pre-post study design, which aimed to perform cost analysis of PCMH from the perspectives of patients, healthcare providers and society. We assessed short-to-intermediate-term health-related costs by analysing data on resource use and unit costs of resources. RESULTS We analysed 165 participants enrolled in PCMH from November 2017 to April 2020, with mean age of 77 years. Compared to the 3-month period before enrolment, mean total direct and indirect participant costs and total health system costs increased, but these were not statistically significant. There was a significant decrease in mean cost for primary care (government primary care and private general practice) in the first 3-month and second 3-month periods after enrolment, accompanied by a significant decrease in service utilisation and mean costs for PCMH services in the second 3-month period post-enrolment. This suggested a shift in resource costs from primary care to community-based care provided by PCMH, which had added benefits of both clinic-based primary care and home-based care management. Findings were consistent with a lower longer-term cost trajectory for PCMH after the initial onboarding period. Indirect caregiving costs remained stable. CONCLUSION The PCMH care model was associated with reduced costs to the health system and patients for usual primary care, and did not significantly change societal costs.
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Affiliation(s)
- Grace Sum
- Geriatric Education and Research Institute, Singapore
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Chiyaka ET, Lanese B, Bruckman D, Redding M, Filla J, Ferguson P, Hoornbeek J. Influence of interaction between community health workers and adults with chronic diseases on risk mitigation through care coordination. INTERNATIONAL JOURNAL OF CARE COORDINATION 2022. [DOI: 10.1177/20534345221092515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction Addressing health disparities and barriers to care requires a comprehensive approach that involves participation of health care providers, multiple organizations, and service providers in the communities affected. Given the importance of using community health workers to help address the complex and overlapping medical, social, and behavioral needs of high-risk individuals, it is of utmost importance to understand their impact on health outcomes. This study examines how in-person interaction between community health workers and their clients influence the client's level of risk mitigation achieved through care coordination using the Pathways Community HUB model. Methods The study utilized two years of data extracted from the Care Coordination Systems database for 391 adults who participated in the Northwest Ohio Pathways Community HUB program. Using multinomial logistic regression analysis, we assessed how the interaction between community health workers and adults with chronic diseases who participated in the Northwest Ohio Pathways Community HUB program influenced the successful mitigation of their social, behavioral, and other medical risks over a 2-year period. Results Our findings show that as the number of in-person contacts between the community health worker and the client increased, the likelihood of completing all Pathways increased by 27% when compared to completing less than 50% of the assigned Pathways, after adjusting for potential confounders (odds ratio: 1.27, 95% confidence interval: 1.07−1.52). Discussion Using community health workers as part of care coordination teams may be effective in connecting communities to systems of care, helping individuals manage their health conditions and connecting individuals to needed social services. Their direct in-person interaction with at-risk individuals may increase the extent to which these individuals successfully address risks to their health and well-being.
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Affiliation(s)
- Edward T Chiyaka
- Center for Public Policy & Health, College of Public Health, Kent State University, Kent, OH, USA
- School of Pharmacy, Wingate University, Wingate, NC, USA
| | - Bethany Lanese
- Center for Public Policy & Health, College of Public Health, Kent State University, Kent, OH, USA
| | - David Bruckman
- Center for Population Health Research, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Redding
- Rebecca D. Considine Research Center, Akron Children's Hospital, Akron, OH, USA
| | - Joshua Filla
- Center for Public Policy & Health, College of Public Health, Kent State University, Kent, OH, USA
| | - Pamela Ferguson
- Research & Evaluation Bureau, College of Education, Health and Human Services, Kent State University, Kent, OH, USA
| | - John Hoornbeek
- Center for Public Policy & Health, College of Public Health, Kent State University, Kent, OH, USA
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Egede LE, Dismuke CE, Walker RJ, Williams JS, Eiler C. Cost-Effectiveness of Technology-Assisted Case Management in Low-Income, Rural Adults with Type 2 Diabetes. Health Equity 2021; 5:503-511. [PMID: 34327293 PMCID: PMC8317594 DOI: 10.1089/heq.2020.0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 01/22/2023] Open
Abstract
Objective: The objective of this study was to examine whether delivering technology-assisted case management (TACM) with medication titration by nurses under physician supervision is cost effective compared with usual care (standard office procedures) in low-income rural adults with type 2 diabetes. Methods: One hundred and thirteen low-income, rural adults with type 2 diabetes and hemoglobin A1c (HbA1c) ≥8%, were randomized to a TACM intervention or usual care. Effectiveness was measured as differences in HbA1c between the TACM and usual care groups at 6 months. Total cost per patient included intervention or usual care cost, medical care cost, and income loss associated with lost workdays. The total cost per patient and HbA1c were used to estimate a joint distribution of incremental cost and incremental effect of TACM compared with usual care. Incremental cost-effectiveness ratios (ICERs) were estimated to summarize the cost-effectiveness of the TACM intervention relative to usual care to decrease HbA1c by 1%. Results: Costs due to intervention, primary care, other health care, emergency room visits, and workdays missed showed statistically significant differences between the groups (usual care $1,360.49 vs. TACM $5,379.60, p=0.004), with an absolute cost difference of $4,019.11. Based on the intervention cost per patient and the change in HbA1c, the median bootstrapped ICERs was estimated to be $6,299.04 (standard error=731.71) per 1% decrease in HbA1c. Conclusion: Based on these results, a 1% decrease in HbA1c can be obtained with the TACM intervention at an approximate cost of $6,300; therefore, it is a cost-effective option for treating vulnerable populations of adults with type 2 diabetes.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Clara E Dismuke
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christian Eiler
- Center for Advancing Population Science, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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5
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Egede LE, Dismuke CE, Eiler C, Williams JS, Walker RJ. Cost-effectiveness of Telephone-Delivered Education and Behavioral Skills Intervention for African American Adults with Diabetes. Ethn Dis 2021; 31:217-226. [PMID: 33883862 DOI: 10.18865/ed.31.2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Purpose Evaluate cost-effectiveness of a telephone-delivered education and behavioral skills intervention in reducing glycemic control (HbA1c) and decreasing risk of complications. Methods Data from a randomized controlled trial, conducted from August 1, 2008 - June 30, 2010 and using a 2x2 factorial design delivered to 255 African American adults not meeting glycemic targets for diabetes were used. Though the primary aim found no significant differences in HbA1c between groups, there was an overall drop in HbA1c across arms and differential cost. Primary clinical outcome was HbA1c measured at 12-months. Costs were estimated based on self-reported utilization of primary care, emergency, and other health care. Costs due to lost wages were calculated based on self-reported days of work missed due to illness. The Michigan Model for Diabetes was used to estimate 10-year probability of developing congestive heart failure, cardiovascular disease, end stage renal disease, stroke, myocardial infarction, all cause death, and CVD death. Total cost per patient and clinical outcomes were used to estimate an incremental cost effectiveness ratio (ICER) using non-parametric bootstrapping. Results ICERs indicated combined education and skills intervention was $3,630 less expensive than usual care to achieve a 0.6% decrease in HbA1c and was between $34,000 and $95,000 less expensive than usual care to reduce risk of complications. The knowledge only intervention was $661 less expensive than usual care and the behavioral skills only intervention did not indicate cost effectiveness. Conclusion The combined intervention ICER for HbA1c is comparable to other education programs and the ICER to reduce the probability of complications falls below previously recommended long-term cut-off of $100,000, suggesting cost-effectiveness in an African American population.
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Affiliation(s)
- Leonard E Egede
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Clara E Dismuke
- Health Economics Resource Center (HERC), VA Palo Alto Health Care System, Palo Alto, CA
| | - Christian Eiler
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Joni S Williams
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
| | - Rebekah J Walker
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI.,Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI
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Pang HY, Farrer C, Wu W, Gakhal NK. Quality of rheumatology care for patients with fibromyalgia and chronic pain syndromes. BMJ Open Qual 2021; 10:bmjoq-2020-001061. [PMID: 33766832 PMCID: PMC7996658 DOI: 10.1136/bmjoq-2020-001061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 11/26/2022] Open
Abstract
Background One-third of primary care providers (PCPs) refer patients with fibromyalgia or chronic pain (FM/CP) to specialist care, typically rheumatology. Yet, comprehensive data on the quality of rheumatology care for patients with FM/CP are currently lacking. Methods Records of patients referred for rheumatology consultation for FM/CP and seen at a single academic centre between 2017 and 2018 were extracted by retrospective chart review. Variables were diagnostic accuracy (at referral vs consultation), resource utilisation (investigations, medications, medical and allied health referral), direct costs (physician billing, staff salary, investigation fees) and access (consult wait time). Patient experience and referring PCP experience surveys were administered. Results 79 charts were identified. Following consultation, 81% of patients (n=64) maintained the same diagnosis of FM/CP, 19% (n=15) were diagnosed with regional pain and 0% of patients (n=0) were diagnosed with an inflammatory arthritis or connective tissue disease. Investigations were ordered for 37% of patients (n=29), medication prescribed for 10% (n=8) and an allied health referral provided for 54% (n=43). Direct costs totalled $19 745 (average $250/consult; range $157–$968/consult). Consultation wait time averaged 184 days (range 62–228 days). Out of the seven (64%) responses to the patient experience survey, 86% of patients (n=6) were satisfied with provider communication but the consultation ‘definitely’ met the expectations of only 57% (n=4). The PCP survey returned an insufficient response rate. Conclusions This study found that no patient referred to rheumatology care for FM/CP was diagnosed with an inflammatory arthritis or connective tissue disease. Furthermore, patients with FM/CP experience lengthy wait times for rheumatology care which delay their management of chronic pain. Interdisciplinary and collaborative healthcare models can potentially provide higher quality care for patients with FM/CP.
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Affiliation(s)
- Hilary Ym Pang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada .,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Chandra Farrer
- Department of Rheumatology, Women's College Hospital, Toronto, Ontario, Canada.,Faculty of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Wei Wu
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Natasha K Gakhal
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Rheumatology, Women's College Hospital, Toronto, Ontario, Canada
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McManus LS, Dominguez-Cancino KA, Stanek MK, Leyva-Moral JM, Bravo-Tare CE, Rivera-Lozada O, Palmieri PA. The Patient-centered Medical Home as an Intervention Strategy for Diabetes Mellitus: A Systematic Review of the Literature. Curr Diabetes Rev 2021; 17:317-331. [PMID: 33231158 DOI: 10.2174/1573399816666201123103835] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Poorly managed diabetes mellitus increases health care expenditures and negatively impacts health outcomes. There are 34 million people living with diabetes in the United States with a direct annual medical cost of $237 billion. The patient-centered medical home (PCMH) was introduced to transform primary care by offering team-based care that is accessible, coordinated, and comprehensive. Although the PCMH is believed to address multiple gaps in delivering care to people living with chronic diseases, the research has not yet reported clear benefits for managing diabetes. OBJECTIVE The study reviews the scientific literature about diabetes mellitus outcomes reported by PCMHs, and understands the impact of team-based care, interdisciplinary communication, and care coordination strategies on the clinical, financial, and health-related outcomes. METHODS The systematic review was performed according to the Cochrane method and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Eight databases were systematically searched for articles. The Oxford Centre for Evidence-based Medicine Levels of evidence and the Critical Appraisal Skills Programme systematic review checklist were used to evaluate the studies. RESULTS The search resulted in 596 articles, of which 24 met all the inclusion criteria. Care management resulted in more screenings and better preventive care. Pharmacy-led interventions and technology were associated with positive clinical outcomes, decreased utilization, and cost savings. Most studies reported decreased emergency room visits and less inpatient admissions. CONCLUSION The quality and strength of the outcomes were largely inconclusive about the overall effectiveness of the PCMH. Defining and comparing concepts across studies was difficult as universal definitions specific to the PCMH were not often applied. More research is needed to unpack the care model of the PCMH to further understand how the individual key components, such as care bundles, contribute to improved outcomes. Further evaluations are needed for team-based care, communication, and care coordination with comparisons to patient, clinical, health, and financial outcomes.
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Affiliation(s)
- Lisa S McManus
- College of Nursing, Walden University, Minneapolis, United States
| | - Karen A Dominguez-Cancino
- Escuela de Enfermería, Universidad Científica del Sur, Lima, Peru
- Evidence-Based Health Care South America: A Joanna Briggs Institute Affiliated Group, Lima, Peru
| | - Michele K Stanek
- Family & Preventive Medicine, School of Medicine, University of South Carolina, Columbia, United States
| | - Juan M Leyva-Moral
- Evidence-Based Health Care South America: A Joanna Briggs Institute Affiliated Group, Lima, Peru
- Department d'Infermeria, Facultat de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
- Center for Global Nursing, Texas Woman’s University, Houston, United States
| | - Carola E Bravo-Tare
- Evidence-Based Health Care South America: A Joanna Briggs Institute Affiliated Group, Lima, Peru
| | - Oriana Rivera-Lozada
- Evidence-Based Health Care South America: A Joanna Briggs Institute Affiliated Group, Lima, Peru
- Vicerrectorado de Investigación, Universidad Norbert Wiener, Lima, Peru
| | - Patrick A Palmieri
- College of Nursing, Walden University, Minneapolis, United States
- Evidence-Based Health Care South America: A Joanna Briggs Institute Affiliated Group, Lima, Peru
- Center for Global Nursing, Texas Woman’s University, Houston, United States
- Vicerrectorado de Investigación, Universidad Norbert Wiener, Lima, Peru
- College of Graduate Health Studies, A. T. Still University, Kirksville, United States
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Guo F, Lin YL, Raji M, Leonard B, Chou LN, Kuo YF. Processes and outcomes of diabetes mellitus care by different types of team primary care models. PLoS One 2020; 15:e0241516. [PMID: 33152002 PMCID: PMC7644045 DOI: 10.1371/journal.pone.0241516] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 10/15/2020] [Indexed: 01/15/2023] Open
Abstract
Background Team care improves processes and outcomes of care, especially for patients with complex medical conditions that require coordination of care. This study aimed to compare the processes and outcomes of care provided to older patients with diabetes by primary care teams comprised of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs). Methods We studied 3,524 primary care practices identified via social network analysis and 306,741 patients ≥66 years old diagnosed with diabetes in or before 2015 in Medicare data. Guideline-recommended diabetes care included eye examination, hemoglobin A1c test, and nephropathy monitoring. High-risk medications were based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Preventable hospitalizations were defined as hospitalizations for a potentially preventable condition. Results Compared with patients in the PCP only teams, patients in the team care practices with NPs or PAs received more guideline-recommended diabetes care (annual eye exam: adjusted odds ratio (aOR): 1.04 (95% CI: 1.00–1.08), 1.08 (95% CI: 1.03–1.13), and 1.10 (95% CI: 1.05–1.15), and HbA1C test: aOR: 1.11 (95% CI: 1.04–1.18), 1.11 (95% CI: 1.02–1.20), and 1.15 (95% CI: 1.06–1.25) for PCP/NP, PCP/NP/PA, and PCP/PA teams). Patients in the PCP/NP and the PCP/PA teams had a slightly higher likelihood of being prescribed high-risk medications (aOR: 1.03 (95% CI: 1.00–1.07), and 1.06 (95% CI: 1.02–1.11), respectively). The likelihood of preventable hospitalizations was similar among patients cared for by various types of practices. Conclusion The team care practices with NPs or PAs were associated with better adherence to clinical practice guideline recommendations for diabetes compared to PCP only practices. Both practices had similar outcomes. Further efforts are needed to explore new and cost-effective team-based care delivery models that improve process, outcomes, and continuity of care, as well as patient care experiences.
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Affiliation(s)
- Fangjian Guo
- Department of Obstetrics & Gynecology, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
| | - Yu-Li Lin
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
| | - Mukaila Raji
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
| | - Bruce Leonard
- School of Nursing, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
| | - Lin-Na Chou
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
| | - Yong-Fang Kuo
- Center for Interdisciplinary Research in Women’s Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Department of Internal Medicine, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Sealy Center on Aging, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- Institute for Translational Science, The University of Texas Medical Branch at Galveston, Galveston, Texas, United States of America
- * E-mail:
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Yue D, Pourat N, Chen X, Lu C, Zhou W, Daniel M, Hoang H, Sripipatana A, Ponce NA. Enabling Services Improve Access To Care, Preventive Services, And Satisfaction Among Health Center Patients. Health Aff (Millwood) 2020; 38:1468-1474. [PMID: 31479374 DOI: 10.1377/hlthaff.2018.05228] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Enabling services address a combination of social determinants of health and barriers to access to primary care and are intended to reduce health disparities. They include care coordination; health education; transportation; and assistance with obtaining food, shelter, and benefits. Empirical evidence of enabling services' potential contribution to health outcomes is limited, which impedes their widespread dissemination. We examined how the receipt of enabling services influenced patient health care outcomes based on a nationally representative survey of patients served in 2014 at health centers funded by the Health Resources and Services Administration. We compared enabling services users and nonusers and found that enabling services were associated with 1.92 more health center visits, an 11.78-percentage-point higher probability of getting a routine checkup, a 16.34-percentage-point higher likelihood of having had a flu shot, and a 7.63-percentage-point higher probability of patient satisfaction. Our results confirm the value of systematic delivery of enabling services in reducing access barriers and improving patient satisfaction.
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Affiliation(s)
- Dahai Yue
- Dahai Yue is a PhD candidate in the Department of Health Policy and Management, University of California Los Angeles (UCLA) Fielding School of Public Health
| | - Nadereh Pourat
- Nadereh Pourat ( ) is a professor in the Department of Health Policy and Management, UCLA Fielding School of Public Health, and director of research and associate director at the UCLA Center for Health Policy Research
| | - Xiao Chen
- Xiao Chen is a senior statistician and associate director of the Health Economics and Evaluation Program at the UCLA Center for Health Policy Research
| | - Connie Lu
- Connie Lu is a project manager and research analyst at the UCLA Center for Health Policy Research
| | - Weihao Zhou
- Weihao Zhou is a statistician at the UCLA Center for Health Policy Research
| | - Marlon Daniel
- Marlon Daniel is a statistician in the Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration (HRSA), in Rockville, Maryland
| | - Hank Hoang
- Hank Hoang is lead for the Data Analytics Team, Office of Quality Improvement, Bureau of Primary Health Care, HRSA
| | - Alek Sripipatana
- Alek Sripipatana is director of the Data and Evaluation Division, Office of Quality Improvement, Bureau of Primary Health Care, HRSA
| | - Ninez A Ponce
- Ninez A. Ponce is a professor in the Department of Health Policy and Management, UCLA Fielding School of Public Health; director of the UCLA Center for Health Policy Research; and principal investigator of the California Health Interview Survey
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Quality of Care and Preventive Screening Use in the CareFirst Patient-Centered Medical Home Program. J Healthc Qual 2020; 41:339-349. [PMID: 30649000 DOI: 10.1097/jhq.0000000000000169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite their value, comprehensive diabetes care and screening for common cancers remain underutilized. We examined the association between participation in a patient-centered medical home (PCMH) program with strong financial incentives and receipt of preventive care in the first 5 years after program launch. Using multivariate regression analysis, we compared outcomes for adults under the care of participating primary care providers (PCPs) with adults under the care of nonparticipating PCPs. Outcomes were breast, cervical and colorectal cancer screenings, and elements of diabetes care. The analytic sample included 818,623 adults living in Maryland, Virginia, or the District of Columbia, and enrolled with CareFirst for at least 1 year during 2010-2015. By Year 5, enrollees in the intervention group were 7.9 (95% confidence interval [CI]: 2.8-13.0), 6.1 (95% CI: 1.4-10.7), 3.1 (95% CI: 2.1-4.0), and 7.6 (95% CI: 7.0-8.2) percentage points more likely to undergo HbA1c tests, nephropathy examinations, breast, and cervical cancer screenings, respectively. We found no significant change in the propensity to receive colorectal cancer screening or an eye examination. Our study shows that a PCMH program with strong financial incentives can raise the provision of preventive care but could require additional adjustment.
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11
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Alvarez C, Saint-Pierre C, Herskovic V, Sepúlveda M, Prieto F. Analysis of the relationship between treatment networks and the evolution of patients with Type 2 Diabetes Mellitus. J Biomed Inform 2020; 108:103497. [PMID: 32621884 DOI: 10.1016/j.jbi.2020.103497] [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: 08/01/2019] [Revised: 04/21/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022]
Abstract
Type 2 Diabetes Mellitus (T2DM) is a chronic disease that has been increasing in prevalence in recent years and that can cause severe complications. To ensure patient care is administered correctly, it is necessary for medical treatment teams to be both multidisciplinary and cohesive. The analysis of health processes is a constant challenge due to their high variability and complexity. This paper proposes a method based on the analysis of social networks to detect treatment networks, and to identify a relationship between these networks and patient evolution, as measured by glycated hemoglobin (HbA1c) levels. The networks were segmented based on patient adherence to their medical appointments and their mean time of delay. We applied this method on a sample of 1574 patients diagnosed with T2DM. Results show that participatory treatment -in which a patient sees a particular group of professionals on a recurrent basis - together with high levels of adherence are associated to those patients who improve their HbA1c levels in the case of high levels of adherence, while those who continually experience referrals to different professionals, remain unstable and, in some cases, get worse. On the other hand, in order to maintain a patient as stable, continuous control of the patient is enough, regardless of the recurrence to the same professionals.
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Affiliation(s)
- Camilo Alvarez
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Cecilia Saint-Pierre
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Valeria Herskovic
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Marcos Sepúlveda
- Computer Science Department, School of Engineering, Pontificia Universidad Católica de Chile, Vicuña Mackenna 4860, Macul, Santiago, Chile.
| | - Florencia Prieto
- Family Medicine Department, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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12
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Levis-Peralta M, González MDR, Stalmeijer R, Dolmans D, de Nooijer J. Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review. Front Endocrinol (Lausanne) 2020; 11:352. [PMID: 32760344 PMCID: PMC7375199 DOI: 10.3389/fendo.2020.00352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 05/05/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Team-based care models (TBC) have demonstrated effectiveness to improve health outcomes for vulnerable diabetes patients but have proven difficult to implement in low income settings. Organizational conditions have been identified as influential on the implementation of TBC. This scoping review aims to answer the question: What is known from the scientific literature about how organizational conditions enable or inhibit TBC for diabetic patients in primary care settings, particularly settings that serve low-income patients? Methods: A scoping review study design was selected to identify key concepts and research gaps in the literature related to the impact of organizational conditions on TBC. Twenty-six articles were finally selected and included in this review. This scoping review was carried out following a directed content analysis approach. Results: While it is assumed that trained health professionals from diverse disciplines working in a common setting will sort it out and work as a team, co-location, and health professions education alone do not improve patient outcomes for diabetic patients. Health system, organization, and/or team level factors affect the way in which members of a care team, including patients and caregivers, collaborate to improve health outcomes. Organizational factors span across seven categories: governance and policies, structure and process, workplace culture, resources, team skills and knowledge, financial implications, and technology. These organizational factors are cited throughout the literature as important to TBC, however, research on the organizational conditions that enable and inhibit TBC for diabetic patients is extremely limited. Dispersed organizational factors are cited throughout the literature, but only one study specifically assesses the effect of organizational factors on TBC. Thematic analysis was used to categorize organizational factors in the literature about TBC and diabetes and a framework for analysis and definitions for key terms is presented. Conclusions: The review identified significant gaps in the literature relating to the study of organizational conditions that enable or inhibit TBC for low-income patients with diabetes. Efforts need to be carried out to establish unifying terminology and frameworks across the field to help explain the relationship between organizational conditions and TBC for diabetes. Gaps in the literature include research be based on organizational theories, research carried out in low-income settings and low and middle income countries, research explaining the difference between the organizational conditions that impact the implementation of TBC vs. maintaining or sustaining TBC and the interaction between organizational factors at the micro, meso and macro level and their impact on TBC. Few studies include information on patient outcomes, and fewer include information on low income settings. Further research is necessary on the impact of organizational conditions on TBC and diabetic patient outcomes.
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Affiliation(s)
| | | | - Renée Stalmeijer
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Diana Dolmans
- Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
| | - Jascha de Nooijer
- Department of Health Promotion, School of Health Professions Education, Maastricht University, Maastricht, Netherlands
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13
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Monestime JP, Biener AI, Wolford M, Mason P. Characteristics of office-based providers associated with secure electronic messaging use: Achieving meaningful use. Int J Med Inform 2019; 129:43-48. [DOI: 10.1016/j.ijmedinf.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 10/27/2022]
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Perez Jolles M, Lengnick-Hall R, Mittman BS. Core Functions and Forms of Complex Health Interventions: a Patient-Centered Medical Home Illustration. J Gen Intern Med 2019; 34:1032-1038. [PMID: 30623387 PMCID: PMC6544719 DOI: 10.1007/s11606-018-4818-7] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 02/03/2023]
Abstract
Despite policy and practice support to develop and test interventions designed to increase access to quality care among high-need patients, many of these interventions fail to meet expectations once deployed in real-life clinical settings. One example is the Patient-Centered Medical Home (PCMH) model, designed to deliver coordinated care. A meta-analysis of PCMH initiatives found mixed evidence of impacts on service access, quality, and costs. Conceptualizing PCMH as a complex health intervention can generate insights into the mechanisms by which this model achieves its effects. It can also address heterogeneity by distinguishing PCMH core functions (the intervention's basic purposes) from forms (the strategies used to meet each function). We conducted a scoping review to identify core functions and forms documented in published PCMH models from 2007 to 2017. We analyzed and summarized the data to develop a PCMH Function and Form Matrix. The matrix contributes to the development of an explicit theory-based depiction of how an intervention achieves its effects, and can guide decision-support tools in the field. This innovative approach can support transformations of clinical settings and implementation efforts by building on a clear understanding of the intervention's standard core functions and the forms adapted to local contexts' characteristics.
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Affiliation(s)
- Mónica Perez Jolles
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 South Olive Street, Suite 1421, Los Angeles, CA 90015 USA
| | - Rebecca Lengnick-Hall
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 1150 South Olive Street, Suite 1421, Los Angeles, CA 90015 USA
| | - Brian S. Mittman
- Health Services Research & Implementation Science, Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
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15
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Miller W, Berg C, Wilson ML, Heard S, Knepper B, Young H. Risk Factors for Below-the-Knee Amputation in Diabetic Foot Osteomyelitis After Minor Amputation. J Am Podiatr Med Assoc 2019; 109:91-97. [PMID: 31135205 DOI: 10.7547/16-143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO. METHODS This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation. RESULTS Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32-47 days) and 16 days for negative margin (interquartile range, 8-29 days). Longer duration of antibiotics was not associated with lower risk of BKA. CONCLUSIONS Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.
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Affiliation(s)
- Whitney Miller
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, CO
| | - Chrystal Berg
- Department of Orthopedics, Denver Health Medical Center and University of Colorado, Denver, CO
| | - Michael L. Wilson
- Department of Pathology and Laboratory Services, Denver Health Medical Center and University of Colorado, Denver, CO
| | - Susan Heard
- Research and Consulting Services, Rocky Mountain Poison and Drug Center, Denver, CO
| | - Bryan Knepper
- Department of Patient Safety and Quality, Denver Health Medical Center, Denver, CO
| | - Heather Young
- Division of Infectious Diseases, Denver Health Medical Center and University of Colorado, Denver, CO
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16
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Peterson J, Hinds A, Garza A, Barner J, Hill L, Nguyen M, Lai P, Gums T. Impact of Physician-Pharmacist Covisits at a Primary Care Clinic in Patients With Uncontrolled Diabetes. J Pharm Pract 2018; 33:321-325. [PMID: 30428760 DOI: 10.1177/0897190018807374] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A popular method for enhancing medication management within a patient-centered medical home (PCMH) is the physician-pharmacist collaborative management (PPCM) model. To improve efficiency of health-care delivery within 4 federally qualified health centers (FQHCs), the PPCM model was implemented through coordinated physician-pharmacist covisits. OBJECTIVE To evaluate the impact of physician-pharmacist covisits on clinical outcomes among patients with uncontrolled diabetes. METHODOLOGY This was a retrospective multicenter cohort study including adults (≥18 years old) with uncontrolled type 1 or type 2 diabetes (hemoglobin A1c [HbA1c] ≥ 8 %) who had at least one covisit between January 1, 2013, and October 1, 2016. The primary clinical metric was mean change in HbA1c from baseline to follow-up. Secondary outcomes included adherence to select American Diabetes Association (ADA) Standards of Medical Care. RESULTS A total of 106 patients were included in this analysis. Patients who were managed in the PPCM model experienced a significant decrease in mean change in HbA1c from baseline to follow-up (-1.75 [2.63], P < .001). There was no significant difference in the proportion of patients receiving recommended vaccinations or cardiovascular (CV) risk reduction medications. CONCLUSION The results suggest that physician-pharmacist covisits may improve glucose control in patients with uncontrolled diabetes.
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Affiliation(s)
- Jasmine Peterson
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA
| | - April Hinds
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA.,Department of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Aida Garza
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA
| | - Jamie Barner
- Department of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Lucas Hill
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA.,Department of Pharmacy, The University of Texas at Austin, Austin, TX, USA
| | - Michelle Nguyen
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA
| | - Phillip Lai
- Department of Pharmacy, CommUnityCare Federally Qualified Health Centers-North Central, Austin, TX, USA
| | - Tyler Gums
- Department of Pharmacy, The University of Texas at Austin, Austin, TX, USA
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Petigara T, Zhang D. Pneumococcal Vaccine Coverage in Adults Aged 19-64 Years, Newly Diagnosed With Chronic Conditions in the U.S. Am J Prev Med 2018; 54:630-636. [PMID: 29551328 DOI: 10.1016/j.amepre.2018.01.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 01/08/2018] [Accepted: 01/29/2018] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This study examined pneumococcal vaccine coverage in adults aged 19-64 years newly diagnosed with diabetes, chronic heart, lung, or liver disease. These conditions are indicated for pneumococcal vaccination by the Advisory Committee on Immunization Practices. METHODS A retrospective cohort analysis was conducted in 2016 using the Truven Health MarketScan® database. The study population was adults aged 19-64 years with at least one new chronic condition during 2009-2013 and continuous health plan enrolment for 2 years before and 1 year after the initial diagnosis. Vaccine coverage by length of follow-up since diagnosis (ranging from 1 to 5 years) was summarized. Multivariate analyses were performed to understand factors associated with vaccination. RESULTS A total of 552,942 adults aged 19-64 years with chronic conditions were identified. There were 8% of adults newly diagnosed with one of four chronic conditions that received a pneumococcal vaccination after 1 year of follow-up; the proportion increased to 20.1% among those with 5 years of follow-up data. Adults aged 50-64 years were more likely to be vaccinated than those aged 19-49 years. Adults with diabetes were more likely to be vaccinated than adults with chronic heart, lung, or liver disease. Adults enrolled in HMO plans were more likely to be vaccinated than adults in other plan types. A higher number of healthcare encounters increased the likelihood of vaccination. Adults who received influenza vaccination were also more likely to receive a pneumococcal vaccination. CONCLUSIONS Vaccine coverage remains well below Healthy People 2020 targets. A substantial number of adults with chronic conditions remain unvaccinated and at risk for pneumococcal disease.
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Affiliation(s)
- Tanaz Petigara
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, New Jersey.
| | - Dongmu Zhang
- Center for Observational and Real-World Evidence, Merck & Co., Inc., Kenilworth, New Jersey
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18
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Sinaiko AD, Landrum MB, Meyers DJ, Alidina S, Maeng DD, Friedberg MW, Kern LM, Edwards AM, Flieger SP, Houck PR, Peele P, Reid RJ, McGraves-Lloyd K, Finison K, Rosenthal MB. Synthesis Of Research On Patient-Centered Medical Homes Brings Systematic Differences Into Relief. Health Aff (Millwood) 2018; 36:500-508. [PMID: 28264952 DOI: 10.1377/hlthaff.2016.1235] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The patient-centered medical home (PCMH) model emphasizes comprehensive, coordinated, patient-centered care, with the goals of reducing spending and improving quality. To evaluate the impact of PCMH initiatives on utilization, cost, and quality, we conducted a meta-analysis of methodologically standardized findings from evaluations of eleven major PCMH initiatives. There was significant heterogeneity across individual evaluations in many outcomes. Across evaluations, PCMH initiatives were not associated with changes in the majority of outcomes studied, including primary care, emergency department, and inpatient visits and four quality measures. The initiatives were associated with a 1.5 percent reduction in the use of specialty visits and a 1.2 percent increase in cervical cancer screening among all patients, and a 4.2 percent reduction in total spending (excluding pharmacy spending) and a 1.4 percent increase in breast cancer screening among higher-morbidity patients. These associations were significant. Identification of the components of PCMHs likely to improve outcomes is critical to decisions about investing resources in primary care.
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Affiliation(s)
- Anna D Sinaiko
- Anna D. Sinaiko is a research scientist in the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Mary Beth Landrum
- Mary Beth Landrum is a professor of biostatistics in the Department of Health Care Policy at Harvard Medical School, in Boston
| | - David J Meyers
- David J. Meyers is a doctoral student in the Department of Health Services, Policy, and Practice at the Brown University School of Public Health, in Providence, Rhode Island
| | - Shehnaz Alidina
- Shehnaz Alidina is a research associate in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
| | - Daniel D Maeng
- Daniel D. Maeng is a research investigator at the Center for Health Research in the Geisinger Health System, in Danville, Pennsylvania
| | - Mark W Friedberg
- Mark W. Friedberg is a senior natural scientist and director at the RAND Corporation in Boston
| | - Lisa M Kern
- Lisa M. Kern is an associate professor of health care policy and research at Weill Cornell Medical College, in New York City
| | - Alison M Edwards
- Alison M. Edwards is a senior research biostatistician at Weill Cornell Medical College
| | - Signe Peterson Flieger
- Signe Peterson Flieger is an assistant professor of public health and community medicine at the Tufts University School of Medicine, in Boston
| | - Patricia R Houck
- Patricia R. Houck is a statistician at UPMC Health Plan, in Pittsburgh, Pennsylvania
| | - Pamela Peele
- Pamela Peele is vice president of health economics at UPMC Health Plan
| | - Robert J Reid
- Robert J. Reid is an affiliate investigator, Group Health Research Institute, in Seattle, Washington
| | - Katharine McGraves-Lloyd
- Katharine McGraves-Lloyd is a senior business information analyst at Anthem Inc., in Washington, D.C
| | - Karl Finison
- Karl Finison is director of analytic development at Onpoint Health Data, in Portland, Maine
| | - Meredith B Rosenthal
- Meredith B. Rosenthal is a professor of health economics and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health
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Min L, Cigolle CT, Bernstein SJ, Ward K, Moore TL, Ha J, Blaum CS. Diabetes care improvement in pharmacist- versus nurse-supported patient-centered medical homes. THE AMERICAN JOURNAL OF MANAGED CARE 2017; 23:e374-e381. [PMID: 29182358 PMCID: PMC6586472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES In 2009 and 2010, 17 primary care sites within 1 healthcare system became patient-centered medical homes (PCMHs), but the sites trained different personnel (pharmacists vs nurses) to improve diabetes care using self-management support (SMS). We report the challenges and successes of our efforts to: 1) assemble a new multipayer (Medicare, Medicaid, commercial) claims dataset linked to a clinical registry and 2) use the new dataset to perform comparative effectiveness research on implementation of the 2 SMS models. STUDY DESIGN Longitudinal cohort study. METHODS We lost permission to use private-payer data. Therefore, we used claims from Medicare fee-for-service and Medicare/Medicaid dual-eligible patients merged with chronic disease registry data. We studied 2008 to 2010, which included 1 year pre- and 1 year post the 2009 implementation time period. Outcomes were outpatient and emergency department visits, hospitalizations, care process (use of statin), and 3 intermediate outcomes (glycemic control, blood pressure [BP], and low-density lipoprotein cholesterol [LDL-C]). RESULTS In our sample of 2826 patients, quality of care improved and utilization decreased over the 2.5 years. Both approaches improved lipid control (LDL-C decreased by an average of 4 mg/dL for pharmacy-SMS and 5.6 mg/dL for nurse-SMS) and diastolic BP (-1.5 mm Hg for pharmacy-SMS and -1.3 mm Hg for nurse-SMS), whereas only the pharmacy-led approach decreased primary care visits (by 0.8 visits). The groups differed slightly on 2 measures (glycated hemoglobin, systolic BP) with respect to the trajectory of improvement over time, but performance was similar by 2.5 years. CONCLUSIONS Diabetes care improved during PCMH implementation systemwide, supporting both nurse-led and pharmacist-led SMS models.
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Affiliation(s)
- Lillian Min
- University of Michigan Medical School, 300 North Ingalls Bldg, Rm 966, Ann Arbor, MI 48109-2007. E-mail:
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Dobbins JM, Peiper N, Jones E, Clayton R, Peterson LE, Phillips RL. Patient-Centered Medical Home Recognition and Diabetes Control Among Health Centers: Exploring the Role of Enabling Services. Popul Health Manag 2017; 21:6-12. [PMID: 28467266 DOI: 10.1089/pop.2017.0001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The patient-centered medical home (PCMH) model has been considered a promising approach to improve chronic care delivery, particularly among patients with diabetes. There is theoretical support to suggest that certain nonmedical services, such as enabling services (eg, case management, social work, transportation), embedded within PCMH could be contributing to successful model implementation. It remains unclear whether PCMH recognition or enabling services are related to diabetes control. Federally Qualified Health Centers (FQHCs) are an important setting in which to study this relationship given the considerable effort required to implement the PCMH model and the ubiquity of enabling services in these safety net settings. This cross-sectional, population-based study used 2012 data from the Health Resources and Services Administration's Uniform Data System and PCMH Recognition Initiative Dataset to determine whether PCMH recognition status was associated with diabetes control rates among FQHCs, while controlling for covariates including enabling services. The study linear regression model estimated that PCMH recognition was associated with a 1.5% increase in the proportion of patients with controlled diabetes (B = 0.015; 95% CI 0.002, 0.027). Clinic region, patient age, and race/ethnicity groups also were related to diabetes control; however, enabling services were not. These findings suggest there is a positive association between PCMH recognition and diabetes control rates among FQHCs. Future research, using data that accurately reflect the provision and utilization of PCMH primary care functions and related enabling services, is needed to fully understand the relationship between the PCMH model and population health measures such as diabetes control.
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Affiliation(s)
- Jessica M Dobbins
- 1 College of Public Health, University of Kentucky , Lexington, Kentucky.,2 School of Public Health and Information Sciences, University of Louisville , Louisville, Kentucky
| | - Nicholas Peiper
- 2 School of Public Health and Information Sciences, University of Louisville , Louisville, Kentucky.,3 Behavioral and Urban Health Program, RTI International , Research Triangle Park, North Carolina
| | - Emily Jones
- 4 Department of Health Policy and Management, The Milken Institute School of Public Health, George Washington University , Washington, District of Columbia
| | - Richard Clayton
- 1 College of Public Health, University of Kentucky , Lexington, Kentucky
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VanArsdale L, Curran-Everett D, Haugen H, Smith N, Atherly A. For Diabetes Shared Savings Programs, 1 Year of Data Is Not Enough. Popul Health Manag 2017; 20:103-113. [PMID: 27455122 PMCID: PMC6436027 DOI: 10.1089/pop.2016.0015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Fee-for-service payment models are moving toward pay-for-performance designs, many of which rely on shared savings for financial sustainability. Shared savings programs divide the cost savings between health care purchaser and provider based on provider performance. Often, these programs measure provider performance as the delivery of agreed-upon clinical practice guidelines that usually are represented as evidence-based medicine (EBM). Multiyear studies show a negative relationship between total cost and EBM, indicating that long-term shared savings can be substantial. This study explores expectations for the rewards in the first year of a shared savings program. It also indicates the effectiveness of using 1 year of claims to assess cost savings from evidence-based care, especially in a patient population with high turnover. This study analyzed 1956 adults with diabetes insured through Medicaid. Results of linear regression showed that the relationship between total cost of care and each element of evidence-based medical care during a 1-year period was positive (higher cost) or insignificant. The results indicate that diabetes EBM programs cannot expect to see significant cost savings if the evaluation lasts only 1 year or less. The study concludes that improvements in EBM incentive programs could come from investigating the length of time needed to realize cost savings from each element of diabetes EBM. Investigating other factors that could affect the expected amount of cost savings also would benefit these programs, especially factors derived from sources external to insurance program information such as the medical record and care management data.
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Affiliation(s)
- Lynne VanArsdale
- The Graduate School, Clinical Sciences, University of Colorado Health Sciences, Aurora, Colorado
| | | | - Heather Haugen
- Health Information Technology, University of Colorado Health Sciences, Aurora, Colorado
| | - Nancy Smith
- Helen and Arthur E. Johnson Beth-El College of Nursing and Health Sciences, University of Colorado Colorado Springs, Colorado Springs, Colorado
| | - Adam Atherly
- Colorado School of Public Health, University of Colorado Health Sciences, Aurora, Colorado
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Malkani S, Keitz SA, Harlan DM. Redesigning Diabetes Care: Defining the Role of Endocrinologists Among Alternative Providers. Curr Diab Rep 2016; 16:121. [PMID: 27766581 DOI: 10.1007/s11892-016-0818-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The current diabetes epidemic threatens to overwhelm the healthcare system unless we redesign how diabetes care is delivered. The number of endocrinologists is grossly inadequate to provide care for all individuals with diabetes, but with the appropriate utilization of the primary care workforce and alternative healthcare providers working together in teams, effective diabetes care can be provided to all. We propose a patient-centered, goal-based approach with resources devoted to care coordination, measurement of outcomes, appropriate use of technology, and measurement of patient satisfaction. Financial incentives to healthcare systems and providers need to be based on defined outcome measures and reducing long-term total medical expenditures, rather than reimbursement based on number of visits and lengthy documentation. Endocrinologists have a responsibility in setting up effective diabetes care delivery systems within their organizations, in addition to delivering diabetes care and serving as a resource for the educational needs for other medical professionals in the community. There are major challenges to implementing such systems, both at the financial and organizational levels. We suggest a stepwise implementation of discrete components based on the local priorities and resources and provide some examples of steps we have taken at our institution.
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Affiliation(s)
- Samir Malkani
- Diabetes Center of Excellence, UMass Medical School, AC4-127, 55 Lake Avenue, Worcester, MA, 01655, USA.
| | - Sheri A Keitz
- Department of Medicine, UMass Medical School, 55 Lake Avenue, Worcester, MA, 01655, USA
| | - David M Harlan
- Diabetes Center of Excellence, UMass Medical School, AC4-127, 55 Lake Avenue, Worcester, MA, 01655, USA
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Abstract
AIMS Fibromyalgia (FM), a chronic disorder defined by widespread pain, often accompanied by fatigue and sleep disturbance, affects up to one in 20 patients in primary care. Although most patients with FM are managed in primary care, diagnosis and treatment continue to present a challenge, and patients are often referred to specialists. Furthermore, the lack of a clear patient pathway often results in patients being passed from specialist to specialist, exhaustive investigations, prescription of multiple drugs to treat different symptoms, delays in diagnosis, increased disability and increased healthcare resource utilisation. We will discuss the current and evolving understanding of FM, and recommend improvements in the management and treatment of FM, highlighting the role of the primary care physician, and the place of the medical home in FM management. METHODS We reviewed the epidemiology, pathophysiology and management of FM by searching PubMed and references from relevant articles, and selected articles on the basis of quality, relevance to the illness and importance in illustrating current management pathways and the potential for future improvements. RESULTS The implementation of a framework for chronic pain management in primary care would limit unnecessary, time-consuming, and costly tests, reduce diagnostic delay and improve patient outcomes. DISCUSSION The patient-centred medical home (PCMH), a management framework that has been successfully implemented in other chronic diseases, might improve the care of patients with FM in primary care, by bringing together a team of professionals with a range of skills and training. CONCLUSION Although there remain several barriers to overcome, implementation of a PCMH would allow patients with FM, like those with other chronic conditions, to be successfully managed in the primary care setting.
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Affiliation(s)
- L. M. Arnold
- Department of PsychiatryUniversity of Cincinnati College of MedicineCincinnatiOHUSA
| | - K. B. Gebke
- Department of Family MedicineIndiana University School of MedicineIndianapolisINUSA
| | - E. H. S. Choy
- Department of MedicineCardiff University School of MedicineCardiffUK
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Abstract
IN BRIEF Diabetic kidney disease carries a heavy burden, both economically and in terms of quality of life, largely because of its very high risk for vascular disease. Coordinated, multidisciplinary care with attention to appropriate, timely screening and preventive management is crucial to reducing the morbidity and mortality of this devastating disease.
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Affiliation(s)
- Koyal Jain
- UNC Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Amy K Mottl
- UNC Kidney Center, University of North Carolina School of Medicine, Chapel Hill, NC
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Purnell JQ, Herrick C, Moreland-Russell S, Eyler AA. Outside the exam room: policies for connecting clinic to community in diabetes prevention and treatment. Prev Chronic Dis 2015; 12:E63. [PMID: 25950570 PMCID: PMC4436047 DOI: 10.5888/pcd12.140403] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The public health burden and racial/ethnic, sex, and socioeconomic disparities in obesity and in diabetes require a population-level approach that goes beyond provision of high-quality clinical care. The Robert Wood Johnson Foundation’s Commission to Build a Healthier America recommended 3 strategies for improving the nation’s health: 1) invest in the foundations of lifelong physical and mental well-being in our youngest children; 2) create communities that foster health-promoting behaviors; and 3) broaden health care to promote health outside the medical system. We present an overview of evidence supporting these approaches in the context of diabetes and suggest policies to increase investments in 1) adequate nutrition through breastfeeding and other supports in early childhood, 2) community and economic development that includes health-promoting features of the physical, food, and social environments, and 3) evidence-based interventions that reach beyond the clinical setting to enlist community members in diabetes prevention and management.
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Affiliation(s)
- Jason Q Purnell
- Brown School, Washington University in St Louis, One Brookings Dr, St Louis, MO 63130.
| | - Cynthia Herrick
- Brown School, Washington University in St Louis, St Louis, Missouri
| | | | - Amy A Eyler
- Brown School, Washington University in St Louis, St Louis, Missouri
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