Facilitating ethical quality improvement initiatives: Design and implementation of an initiative-specific ethics committee

Impact of Referring High-Risk Patients to Intensive Outpatient Primary Care Services: A Propensity Score-Matched Analysis

BACKGROUND

Many healthcare systems have implemented intensive outpatient primary care programs with the hopes of reducing healthcare costs.

OBJECTIVE

The Veterans Health Administration (VHA) piloted primary care intensive management (PIM) for patients at high risk for hospitalization or death, or "high-risk." We evaluated whether a referral model would decrease high-risk patient costs.

DESIGN

Retrospective cohort study using a quasi-experimental design comparing 456 high-risk patients referred to PIM from October 2017 to September 2018 to 415 high-risk patients matched on propensity score.

PARTICIPANTS

Veterans in the top 10th percentile of risk for 90-day hospitalization or death and recent hospitalization or emergency department (ED) visit.

INTERVENTION

PIM consisted of interdisciplinary teams that performed comprehensive assessments, intensive case management, and care coordination services.

MAIN OUTCOMES AND MEASURES

Change in VHA and non-VHA outpatient utilization, inpatient admissions, and costs 12 months pre- and post-index date.

KEY RESULTS

Of the 456 patients referred to PIM, 301 (66%) enrolled. High-risk patients referred to PIM had a marginal reduction in ED visits (- 0.7; [95% CI - 1.50 to 0.08]; p = 0.08) compared to propensity-matched high-risk patients; overall outpatient costs were similar. High-risk patients referred to PIM had similar number of medical/surgical hospitalizations (- 0.2; [95% CI, - 0.6 to 0.16]; p = 0.2), significant increases in length of stay (6.36; [CI, - 0.01 to 12.72]; p = 0.05), and higher inpatient costs ($22,628, [CI, $3587 to $41,669]; p = 0.02) than those not referred to PIM.

CONCLUSIONS AND RELEVANCE

VHA intensive outpatient primary care was associated with higher costs. Referral to intensive case management programs targets the most complex patients and may lead to increased utilization and costs, particularly in an integrated healthcare setting with robust patient-centered medical homes.

TRIAL REGISTRATION

PIM 2.0: Patient Aligned Care Team (PACT) Intensive Management (PIM) Project (PIM2). NCT04521816. https://clinicaltrials.gov/study/NCT04521816.

Types of Engagement Strategies to Engage High-Risk Patients in VA

BACKGROUND

Many healthcare systems seek to improve care for complex high-risk patients, but engaging such patients to actively participate in their healthcare can be challenging.

OBJECTIVE

To identify and describe types of patient engagement strategies reported as successfully deployed by providers/teams and experienced by patients in a Veterans Health Administration (VA) intensive primary care (IPC) pilot program.

METHODS

We conducted semi-structured qualitative telephone interviews with 29 VA IPC staff (e.g., physicians, nurses, psychologists) and 51 patients who had at least four IPC team encounters. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach.

RESULTS

The engagement strategies successfully deployed by the IPC providers/teams could be considered either more "facilitative," i.e., facilitated by and dependent on staff actions, or more "self-sustaining," i.e., taught to patients, thus cultivating their ongoing patient self-care. Facilitative strategies revolved around enhancing patient access and coordination of care, trust-building, and addressing social determinants of health. Self-sustaining strategies were oriented around patient empowerment and education, caregiver and/or community support, and boundaries and responsibilities. When patients described their experiences with the "facilitative" strategies, many discussed positive proximal outcomes (e.g., increased access to healthcare providers). Self-sustaining strategies led to positive (self-reported) longer-term clinical outcomes, such as behavior change.

CONCLUSION

We identified two categories of strategies for successfully engaging complex, high-risk patients: facilitative and self-sustaining. Intensive primary care program leaders may consider thoughtfully building "self-sustaining" engagement strategies into program development. Future research can confirm their effectiveness in improving health outcomes.

Outcomes that Matter: High-Needs Patients' and Primary Care Leaders' Perspectives on an Intensive Primary Care Pilot

BACKGROUND

Quantitative evaluations of the effectiveness of intensive primary care (IPC) programs for high-needs patients have yielded mixed results for improving healthcare utilization, cost, and mortality. However, IPC programs may provide other value.

OBJECTIVE

To understand the perspectives of high-needs patients and primary care facility leaders on the effects of a Veterans Affairs (VA) IPC program on patients.

DESIGN

A total of 66 semi-structured telephone interviews with high-needs VA patients and primary care facility leaders were conducted as part of the IPC program evaluation.

PARTICIPANTS

High-needs patients (n = 51) and primary care facility leaders (n = 15) at 5 VA pilot sites.

APPROACH

We used content analysis to examine interview transcripts for both a priori and emergent themes about perceived IPC program effects.

KEY RESULTS

Patients enrolled in VA IPCs reported improvements in their experience of VA care (e.g., patient-provider relationship, access to their team). Both patients and leaders reported improvements in patient motivation to engage with self-care and with their IPC team, and behaviors, especially diet, exercise, and medication management. Patients also perceived improvements in health and described receiving assistance with social needs. Despite this, patients and leaders also outlined patient health characteristics and contextual factors (e.g., chronic health conditions, housing insecurity) that may have limited the effectiveness of the program on healthcare cost and utilization.

CONCLUSIONS

Patients and primary care facility leaders report benefits for high-needs patients from IPC interventions that translated into perceived improvements in healthcare, health behaviors, and physical and mental health status. Most program evaluations focus on cost and utilization, which may be less amenable to change given this cohort's numerous comorbid health conditions and complex social circumstances. Future IPC program evaluations should additionally examine IPC's effects on quality of care, patient satisfaction, quality of life, and patient health behaviors other than utilization (e.g., engagement, self-efficacy).

The ethics of quality improvement studies: do the needs of the many outweigh the needs of the few?

Clinical research involving human subjects and quality improvement (QI) projects share a common goal of seeking to improve human health, whether by directly changing the standard of care (research) or by improving the process(es) by which that care is delivered (QI). Whether a QI project requires informed consent (written or oral) is a function of the risk-benefit analysis of the study; such a determination should not be at the sole discretion of the investigators, but should come from an appropriately constituted review board with expertise in the ethics of biomedical research.

Outcomes of a randomized quality improvement trial for high-risk Veterans in year two

OBJECTIVE

The Veterans Health Administration (VHA) conducted a randomized quality improvement evaluation to determine whether augmenting patient-centered medical homes with Primary care Intensive Management (PIM) decreased utilization of acute care and health care costs among patients at high risk for hospitalization. PIM was cost-neutral in the first year; we analyzed changes in utilization and costs in the second year.

DATA SOURCES

VHA administrative data for five demonstration sites from August 2013 to March 2019.

DATA SOURCES

Administrative data extracted from VHA's Corporate Data Warehouse.

STUDY DESIGN

Veterans with a risk of 90-day hospitalization in the top 10th percentile and recent hospitalization or emergency department (ED) visit were randomly assigned to usual primary care vs primary care augmented by PIM. PIM included interdisciplinary teams, comprehensive patient assessment, intensive case management, and care coordination services. We compared the change in mean VHA inpatient and outpatient utilization and costs (including PIM expenses) per patient for the 12-month period before randomization and 13-24 months after randomization for PIM vs usual care using difference-in-differences.

PRINCIPAL FINDINGS

Both PIM patients (n = 1902) and usual care patients (n = 1882) had a mean of 5.6 chronic conditions. PIM patients had a greater number of primary care visits compared to those in usual care (mean 4.6 visits/patient/year vs 3.7 visits/patient/year, p < 0.05), but ED visits (p = 0.45) and hospitalizations (p = 0.95) were not significantly different. We found a small relative increase in outpatient costs among PIM patients compared to those in usual care (mean difference + $928/patient/year, p = 0.053), but no significant differences in mean inpatient costs (+$245/patient/year, p = 0.97). Total mean health care costs were similar between the two groups during the second year (mean difference + $1479/patient/year, p = 0.73).

CONCLUSIONS

Approaches that target patients solely based on the high risk of hospitalization are unlikely to reduce acute care use or total costs in VHA, which already offers patient-centered medical homes.