Primary care and accountable care--two essential elements of delivery-system reform

How to facilitate the introduction of value-based payment models?

Value-based payment (VBP) models are designed and implemented to improve outcomes at the same or lower costs. Their adoption requires significant changes in the way healthcare organisations and insurance companies operate. Usually, before VBP models are widely implemented, pilot projects are conducted. Payers need to have a comprehensive set of requirements to enter into agreements with healthcare organisations on these pilots. In this short communication, we outline key elements reported in the literature, inside and outside healthcare organisations, as well as within the contract, that need to be considered in a pilot VBP model. Discussions regarding the introduction of VBP models may be strongly affected by external contextual factors, including regulations, which are outside the control of healthcare organisations. It requires collaboration between organisations, including primary care organisations and hospitals, while within organisations, it frequently requires creating multidisciplinary teams. The focus is on ensuring transparency, collaboration, and shared decision-making, realised by standardising communication processes and regular meetings. Additionally, effective leadership is needed, in which leaders set goals and priorities, as well as manage change. In the contractual agreements between payers and healthcare organisations, outcome measures need to be adequately defined and measured, including individual patient outcomes and composite scores, as well as absolute and relative performance measures. These measures should be tested periodically and catered to the organisations adopting the model. Also, incentives should have adequate size and frequency and be intrinsic and extrinsic. The consideration of these sets of key elements by the payers is essential when implementing VBP model pilot projects.

Indian Model of Integrated Healthcare (IMIH): a conceptual framework for a coordinated referral system in resource-constrained settings

INTRODUCTION

With the escalating burden of chronic disease and multimorbidity in India, owing to its ageing population and overwhelming health needs, the Indian Health care delivery System (HDS) is under constant pressure due to rising public expectations and ambitious new health goals. The three tired HDS should work in coherence to ensure continuity of care, which needs a coordinated referral system. This calls for optimising health care through Integrated care (IC). The existing IC models have been primarily developed and adopted in High-Income Countries. The present study attempts to review the applicability of existing IC models and frame a customised model for resource-constrained settings.

METHODS

A two-stage methodology was used. Firstly, a narrative literature review was done to identify gaps in existing IC models, as per the World Health Organization framework approach. The literature search was done from electronic journal article databases, and relevant literature that reported conceptual and theoretical concepts of IC. Secondly, we conceptualised an IC concept according to India's existing HDS, validated by multiple rounds of brainstorming among co-authors. Further senior co-authors independently reviewed the conceptualised IC model as per national relevance.

RESULTS

Existing IC models were categorised as individual, group and disease-specific, and population-based models. The limitations of having prolonged delivery time, focusing only on chronic diseases and being economically expensive to implement, along with requirement of completely restructuring and reorganising the existing HDS makes the adoption of existing IC models not feasible for India. The Indian Model of Integrated Healthcare (IMIH) model proposes three levels of integration: Macro, Meso, and Micro levels, using the existing HDS. The core components include a Central Gateway Control Room, using existing digital platforms at macro levels, a bucket overflow model at the meso level, a Triple-layered Concentric Circle outpatient department (OPD) design, and a three-door OPD concept at the micro level.

CONCLUSION

IMIH offers features that consider resource constraints and local context of LMICs while being economically viable. It envisages a step toward UHC by optimising existing resources and ensuring a continuum of care. However, health being a state subject, various socio-political and legal/administrative issues warrant further discussion before implementation.

The health impact of freight transport-related air pollution on vulnerable population groups

Every year, over 364,200 people in Europe die prematurely due to the effects of air pollution, in which the transportation sector plays an important role. In Brussels, freight transport generates €61,604 of air pollution health costs daily. Research has shown that dynamic spatiotemporal modeling of both emission sources and exposed people (using mobile phone data) renders more accurate impact results when analyzed in microenvironments. However, mobile data underrepresent population segments that are more sensitive to the effects of air pollution, such as toddlers, children and elderly individuals. This paper examined the link between vulnerable people aged 0-3, 3-18 and >65 years and freight transport-related air pollution concentrations in the Brussels-Capital Region (BCR). To this end, dynamic tailpipe emissions and their spatiotemporal dispersion were calculated using output from the Transport Agent-Based Model (TRABAM) on a daily basis. Population densities were calculated as a function of the residences' occupancy rate and school/class size and opening hours. The effects of exposure were then evaluated using age- and sex-differentiated exposure-response functions and monetized using local hospital cost factors. Data were compiled for 2021. A strong overlap between people's presence at the institutions' locations was noticed with a peak in (freight) transportation movements in the city. The results showed that €37,000 [€34,517.47-€40,047.13] of freight transport-related air pollution health costs were incurred daily by vulnerable population segments. While these vulnerable groups made up 25.34% of the total BCR population, they incurred 60% [56.03%-65.01%] of the engendered transportation air pollution costs. The results were then geographically analyzed to identify 465 traffic-related air pollution hotspots across the territory, which accounted for €36,000 [€33,677.85-€39,101.31] of total costs. The latter can be used in future studies to assess sector-specific freight transportation policies, which should take into consideration spatiotemporal population densities on the local level.

When is caring sharing? Primary care provider interdependence and continuity of care

ABSTRACT

Efforts to improve access to high-quality, efficient primary care have highlighted the need for team-based care. Most primary care teams are designed to maintain continuity of care between patients and primary care providers (PCPs), because continuity of care can improve some patient outcomes. However, PCPs are interdependent because they care for, or share, patients. PCP interdependence, and its association with continuity of care, is not well described. This study describes a measure of PCP interdependence. We also evaluate the association between patient and panel characteristics, including PCP interdependence. Our results found that the extent of interdependence between PCPs in the same clinic varies widely. A range of patient and panel characteristics affect continuity of care, including patient complexity and PCP interdependence. These results suggest that continuity of care for complex patients is sensitive to panel characteristics, including PCP interdependence and panel size. This information can be used by primary care organizations for evidence-based team design.

Rethinking Primary Care Delivery Models: Can Integrated Primary Care Teams Improve Care Experience?

Background:

Integrated Primary Care Teams (IPCTs) have four key characteristics (intensive interdisciplinary practice; advanced nursing practice with an expanded role; group practice; increased proximity and availability) aimed at strengthening primary care in Quebec, Canada. The purpose of this paper is to examine the care experience over time of patients who have an IPCT as their primary source of care.

Methods:

We used a quasi-experimental longitudinal design based on a pre-and-post administered survey at a 2-year interval without a control group. We measured patient-reported accessibility, continuity, comprehensiveness, responsiveness and outcomes of care.

Results:

Results showed that patients who were newly registered with an IPCT had a significant increase in reported care experience, whereas patients who have been registered with an IPCT for 2 years prior to the first round of data collection had already high reported care experience that was maintained over time. Moreover, linear regression models showed statistically significant different increases in the dimensions of care experience by site and patients’ characteristics.

Conclusions:

Our results suggest that the IPCT model is tailored to the needs of its target populations, resulting in improved Patient Reported Experience Measures. These results imply that broader implementation of innovative and flexible community-based care models should be considered by policymakers.

Association between primary care appointment lengths and subsequent ambulatory reassessment, emergency department care, and hospitalization: a cohort study

Background

To meet increasing demand, healthcare systems may leverage shorter appointment lengths to compensate for a limited supply of primary care providers (PCPs). Limiting the time spent with patients when evaluating acute health needs may adversely affect quality of care and increase subsequent healthcare utilization; however, the impact of brief duration appointments on healthcare utilization in the United States has not been examined. This study aimed to assess for potential inferiority of shorter (15-min) primary care appointments compare to longer (≥ 30-min appointments) with respect to downstream healthcare utilization within 7 days of the initial appointment.

Methods

We performed a retrospective cohort study using electronic health record (EHR), billing, and administrative scheduling data from five primary care practices in Midwest United States. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 were included. Patients scheduled for 15-min appointments were propensity score matched to those scheduled for ≥ 30-min. Multivariate regression models examined the effects of appointment length on repeat primary care visits, emergency department (ED) visits, hospitalizations, and diagnostic services within 7 days following the visit. Models were adjusted for baseline patient, visit, and provider characteristics. A non-inferiority approach was employed.

Results

We identified 173,758 total index visits (6.5% 15-min, 93.5% ≥ 30-min). 11,222 15-min appointments were matched to a comparable ≥ 30-min visit. Longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities. There was no significant effect of scheduled appointment length on the incidence of repeat primary care visits (OR = 0.983, CI: 0.873, 1.106) or ED visits (OR = 0.856, CI: 0.700, 1.047). Shorter appointments were associated with lower rates of subsequent hospitalizations (OR = 0.689, CI: 0.504, 0.941), laboratory services (OR = 0.682, CI: 0.643, 0.724), and diagnostic imaging services (OR = 0.499, CI: 0.466, 0.534). None of the non-inferiority thresholds were exceeded.

Conclusions

For select indications and select low risk patients, shorter duration appointments may be a non-inferior option for scheduling of patient care that will not result in greater downstream healthcare utilization. These findings can help inform healthcare delivery models and triage processes as health systems and payers re-examine how to best deliver care to growing patient populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01644-8.

The primary spine practitioner as a new role in healthcare systems in North America

Background

In an article published in 2011, we discussed the need for a new role in health care systems, referred to as the Primary Spine Practitioner (PSP). The PSP model was proposed to help bring order to the chaotic nature of spine care. Over the past decade, several efforts have applied the concepts presented in that article. The purpose of the present article is to discuss the ongoing need for the PSP role in health care systems, present persistent barriers, report several examples of the model in action, and propose future strategies.

Main body

The management of spine related disorders, defined here as various disorders related to the spine that produce axial pain, radiculopathy and other related symptoms, has received significant international attention due to the high costs and relatively poor outcomes in spine care. The PSP model seeks to bring increased efficiency, effectiveness and value. The barriers to the implementation of this model have been significant, and responses to these barriers are discussed. Several examples of PSP integration are presented, including clinic systems in primary care and hospital environments, underserved areas around the world and a program designed to reduce surgical waiting lists. Future strategies are proposed for overcoming the continuing barriers to PSP implementation in health care systems more broadly.

Conclusion

Significant progress has been made toward integrating the PSP role into health care systems over the past 10 years. However, much work remains. This requires substantial effort on the part of those involved in the development and implementation of the PSP model, in addition to support from various stakeholders who will benefit from the proposed improvements in spine care.

Trends in quality of primary care in the United States, 2007-2016

During the past decade, many reforms were proposed and implemented for improving primary care in the US. This study assessed improvements in quality of primary care, using a nationally representative database. We conducted a retrospective trend analysis of National Inpatient Sample data (2007–2016). The quality of primary care was assessed using Prevention Quality Indicators (PQIs), which consist of 13 sets of preventable hospitalization conditions. PQI hospitalization decreased from 154,565 to 151,168 per million hospitalizations during the study period (relative decrease, 2.2%; P = 0.041). Age-adjusted hospitalization rate increased for diabetes short-term complications (relative increase, 46.9%; P < 0.001) and lower-extremity amputations (relative increase, 15.1%; P = 0.035). Age stratified trends showed that hospitalization rates decreased significantly in all age-groups for diabetes short-term complications. For lower-extremity amputations, hospitalization rates increased significantly in younger age groups and decreased significantly in the older age groups. All other PQIs showed either decreasing or no change in trends. Adults aged 18–64 years should be the focus for future prevention attempts for diabetes complications. Identifying and acting on the factors responsible for these changes could help in reversing the concerning trends observed in this study. Existing strategies should focus on improving access to diabetes care and self-management.

Longitudinal participation in delivery and payment reform programs among US Primary Care Organizations

OBJECTIVE

To assess longitudinal primary care organization participation patterns in large-scale reform programs and identify organizational characteristics associated with multiprogram participation.

DATA SOURCES

Secondary data analysis of national program participation data over an eight-year period (2009-2016).

STUDY DESIGN

We conducted a retrospective, observational study by creating a unique set of data linkages (including Medicare and Medicaid Meaningful Use and Medicare Shared Savings Program Accountable Care Organization (MSSP ACO) participation from CMS, Patient-Centered Medical Home (PCMH) participation from the National Committee for Quality Assurance, and organizational characteristics) to measure longitudinal participation and identify what types of organizations participate in one or more of these reform programs. We used multivariate models to identify organizational characteristics that differentiate those that participate in none, one, or two-to-three programs.

DATA EXTRACTION METHODS

We used Medicare claims to identify organizations that delivered primary care services (n = 56 ,287) and then linked organizations to program participation data and characteristics.

PRINCIPAL FINDINGS

No program achieved more than 50% participation across the 56,287 organizations in a given year, and participation levels flattened or decreased in later years. 36% of organizations did not participate in any program over the eight-year study period; 50% participated in one; 13% in two; and 1% in all three. 14.31% of organizations participated in five or more years of Meaningful Use while 3.84% of organizations participated in five years of the MSSP ACO Program and 0.64% participated in at least five years of PCMH. Larger organizations, those with younger providers, those with more primary care providers, and those with larger Medicare patient panels were more likely to participate in more programs.

CONCLUSIONS AND RELEVANCE

Primary care transformation via use of voluntary programs, each with their own participation requirements and approach to incentives, has failed to broadly engage primary care organizations. Those that have chosen to participate in multiple programs are likely those already providing high-quality care.

The Value of the Patient-Centered Medical Home in Getting Adults Suffering From Acute Conditions Back to Work: An Integrative Literature Review

Acute conditions are the leading cause of work restrictions and missed workdays, contributing to over $27 billion in lost productivity each year and negatively impacting workers' health and quality of life. Primary care services, specifically patient-centered medical homes (PCMHs), play an essential role in supporting timely acute illness or injury recovery for working adults. The purpose of this review is to synthesize the evidence on the relationship between PCMH implementation, care processes, and outcomes. In addition, we discuss the empirical connection between this evidence and return-to-work outcomes, as well as the need for further research.

Nurse staffing and patient-perceived quality of nursing care: a cross-sectional analysis of survey and administrative data in German hospitals

OBJECTIVE

To examine the impact of nurse staffing on patient-perceived quality of nursing care. We differentiate nurse staffing levels and nursing skill mix as two facets of nurse staffing and use a multidimensional instrument for patient-perceived quality of nursing care. We investigate non-linear and interaction effects.

SETTING

The study setting was 3458 hospital units in 1017 hospitals in Germany.

PARTICIPANTS

We contacted 212 554 patients discharged from non-paediatric, non-intensive and non-psychiatric hospital units who stayed at least two nights in the hospital between January and October 2019. Of those, 30 174 responded, yielding a response rate of 14.2%. Our sample included only those patients. After excluding extreme values for our nurse staffing variables and removing observations with missing values, our final sample comprised 28 136 patients ranging from 18 to 97 years of age (average: 61.12 years) who had been discharged from 3458 distinct hospital units in 1017 hospitals.

PRIMARY AND SECONDARY OUTCOME MEASURES

Patient-perceived quality of nursing care (general nursing care, guidance provided by nurses, and patient loyalty to the hospital).

RESULTS

For all three dimensions of patient-perceived quality of nursing care, we found that they significantly decreased as (1) nurse staffing levels decreased (with decreasing marginal effects) and (2) the proportion of assistant nurses in a hospital unit increased. The association between nurse staffing levels and quality of nursing care was more pronounced among patients who were less clinically complex, were admitted to smaller hospitals or were admitted to medical units.

CONCLUSIONS

Our results indicate that, in addition to nurse staffing levels, nursing skill mix is crucial for providing the best possible quality of nursing care from the patient perspective and both should be considered when designing policies such as minimum staffing regulations to improve the quality of nursing care in hospitals.

Health Behavior Change Programs in Primary Care and Community Practices for Cardiovascular Disease Prevention and Risk Factor Management Among Midlife and Older Adults: A Scientific Statement From the American Heart Association

Cardiovascular disease predominates as the leading health burden among middle-aged and older American adults, but progress in improving cardiovascular health remains slow. Comprehensive, evidenced-based behavioral counseling interventions in primary care are a recommended first-line approach for promoting healthy behaviors and preventing poor cardiovascular disease outcomes in adults with cardiovascular risk factors. Assisting patients to adopt and achieve their health promotion goals and arranging follow-up support are critical tenets of the 5A Model for behavior counseling in primary care. These 2 steps in behavior counseling are considered essential to effectively promote meaningful and lasting behavior change for primary cardiovascular disease prevention. However, adoption and implementation of behavioral counseling interventions in clinical settings can be challenging. The purpose of this scientific statement from the American Heart Association is to guide primary health care professional efforts to offer or refer patients for behavioral counseling, beyond what can be done during brief and infrequent office visits. This scientific statement presents evidence of effective behavioral intervention programs that are feasible for adoption in primary care settings for cardiovascular disease prevention and risk management in middle-aged and older adults. Furthermore, examples are provided of resources available to facilitate the widespread adoption and implementation of behavioral intervention programs in primary care or community-based settings and practical approaches to appropriately engage and refer patients to these programs. In addition, current national models that influence translation of evidence-based behavioral counseling in primary care and community settings are described. Finally, this scientific statement highlights opportunities to enhance the delivery of equitable and preventive care that prioritizes effective behavioral counseling of patients with varying levels of cardiovascular disease risk.

Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector

People with serious mental illness die 10-20 years earlier, compared with the overall population, and the excess mortality is driven by undertreated physical health conditions. In the United States, there is growing interest in models integrating physical health care delivery, management, or coordination into specialty mental health programs, sometimes called "reverse integration." In November 2019, the Johns Hopkins ALACRITY Center for Health and Longevity in Mental Illness convened a forum of 25 experts to discuss the current state of the evidence on integrated care models based in the specialty mental health system and to identify priorities for future research, policy, and practice. This article summarizes the group's conclusions. Key research priorities include identifying the active ingredients in multicomponent integrated care models and developing and validating integration performance metrics. Key policy and practice recommendations include developing new financing mechanisms and implementing strategies to build workforce and data capacity. Forum participants also highlighted an overarching need to address socioeconomic risks contributing to excess mortality among adults with serious mental illness.

Staffing levels and nursing-sensitive patient outcomes: Umbrella review and qualitative study

OBJECTIVE

To derive a comprehensive list of nursing-sensitive patient outcomes (NSPOs) from published research on nurse staffing levels and from expert opinion.

DATA SOURCES/STUDY SETTING

Published literature reviews and their primary studies analyzing the link between nurse staffing levels and NSPOs and interviews with 16 experts on nursing care.

STUDY DESIGN

Umbrella review and expert interviews.

DATA COLLECTION/EXTRACTION METHODS

We screened three electronic databases for literature reviews on the association between nurse staffing levels and NSPOs. After screening 430 potentially relevant records, we included 15 literature reviews, derived a list of 22 unique NSPOs from them, and ranked these in a systematic fashion according to the strength of evidence existing for their association with nurse staffing. We extended this list of NSPOs based on data from expert interviews.

PRINCIPAL FINDINGS

Of the 22 NSPOs discussed in the 15 included literature reviews, we rated the strength of evidence for four as high, for five as moderate, and for 13 outcomes as low. Four additional NSPOs that have not been considered in literature were identified through expert interviews.

CONCLUSIONS

We identified strong evidence for a significant association between nurse staffing levels and NSPOs. Our results may guide researchers in selecting NSPOs they might wish to prioritize in future studies. In particular, rarely studied NSPOs as well as NSPOs that were only identified through expert interviews but have not been considered in literature so far should be subject to further research.

Factors Affecting Primary Care Implementation for Older Veterans with multimorbidity in VA

OBJECTIVE

To identify factors affecting implementation of Geriatric Patient Aligned Care Teams (GeriPACT), a patient-centered medical home model for older adults with complex care needs including multiple chronic conditions (MCC), designed to provide them with comprehensive, managed and coordinated primary care.

DATA SOURCES

Qualitative data was collected from key informants at eight VA Medical Centers (VAMCs) geographically spread across the US.

STUDY DESIGN

Guided by the Consolidated Framework for Implementation Research (CFIR), we collected prospective primary data through semi-structured interviews with GeriPACT team members (e.g. physicians, nurses, social workers, pharmacists), leaders (e.g., executive leaders and middle managers), and other staff referring to the program.

DATA COLLECTION

We conducted in-person, semi-structured interviews with 134 key informants. Interviews were recorded with permission and professionally transcribed. Transcripts were coded in NVIVO 11. We used directed content analysis to identify key factors affecting GeriPACT implementation across sites.

PRINCIPAL FINDINGS

Five key factors affected GeriPACT implementation-5 CFIR constructs within two CFIR domains. Within the intervention characteristics domain, two constructs emerged: 1) the structure of the GeriPACT model, and 2) design, quality and packaging. In the inner setting domain, we identified three constructs: 1) available resources (e.g., staffing and space, and infrastructure and information technology; 2) leadership support and engagement, and 3) networks and communications including teamwork, communication and coordination.

CONCLUSIONS

Older Veterans with MCC have complex primary care needs requiring high levels of care management and coordination. Knowing what key factors affect GeriPACT implementation is critical. Study findings also contribute to the growing implementation science literature on applying CFIR to evaluate factors that affect program implementation, especially to aging research. Further studies on MCC-focused specialty primary care will help facilitate patient-centered care provision for older adults' complex health needs while also leveraging synergistic work across factors affecting implementation. This article is protected by copyright. All rights reserved.

The association of insurance plan characteristics with physician patient-sharing network structure

Professional and social connections among physicians impact patient outcomes, but little is known about how characteristics of insurance plans are associated with physician patient-sharing network structure. We use information from commercially insured enrollees in the 2011 Massachusetts All Payer Claims Database to construct and examine the structure of the physician patient-sharing network using standard and novel social network measures. Using regression analysis, we examine the association of physician patient-sharing network measures with an indicator of whether a patient is enrolled in a health maintenance organization (HMO) or preferred provider organization (PPO), controlling for patient and insurer characteristics and observed health status. We find patients enrolled in HMOs see physicians who are more central and densely embedded in the patient-sharing network. We find HMO patients see PCPs who refer to specialists who are less globally central, even as these specialists are more locally central. Our analysis shows there are small but significant differences in physician patient-sharing network as experienced by patients with HMO versus PPO insurance. Understanding connections between physicians is essential and, similar to previous findings, our results suggest policy choices in the insurance and delivery system that change physician connectivity may have important implications for healthcare delivery, utilization and costs.

Associations of patient-centered medical home with quality of care, patient experience, and health expenditures: A STROBE-compliant cross-sectional study

In efforts to improve the delivery of quality primary care, patient-centered medical home (PCMH) model has been promoted. However, evidence on its association with health outcomes has been mixed. The aim of this study was to assess the performance of PCMH model on quality of care, patient experience, health expenditures.This was a cross-sectional study of the 2015-2016 Medical Expenditure Panel Survey-Medical Organization Survey linked data, including 5748 patient-provider pairs. We examined twenty-four quality of care measures (18 high-value and 6 low-value care services), health service utilization, patient experience (patient-provider communication, satisfaction), and health expenditure.Of 5748 patients, representing a weighted population of 56.2 million American adults aged 18 years and older, 44.2% were cared for by PCMH certified providers. 9.3% of those with PCMHs had at least one inpatient stay in the past year, which was comparable to the 11.4% among those with non-PCMHs. Similarly, 17.4% of respondents cared for by PCMH and 18.5% cared for by non-PCMH had at least one ED visit. Overall, we found no significant differences in quality of care measures (neither high-nor low-value of care) between the two groups. The overall satisfaction, the experience of access to care, and communication with providers were also comparable. Patients who were cared for by PCMHs had less total health expenditure (difference $217) and out-of-pocket spending (difference $91) than those cared for by non-PCMHs; however, none of these differences reached the statistical significance (adjusted P > 0.05 for all).This study found no meaningful difference in quality of care, patient experience, health care utilization, or health care expenditures between respondents cared for by PCMH and non-PCMH. Our findings suggest that the PCMH model is not superior in the quality of care delivered to non-PCMH providers.

Out-Of-Network Primary Care Is Associated With Higher Per Beneficiary Spending In Medicare ACOs

Despite expectations that Medicare accountable care organizations (ACOs) would curb health care spending, their effect has been modest. One possible explanation is that ACOs' inability to prohibit out-of-network care limits their control over spending. To examine this possibility, we examined the association between out-of-network care and per beneficiary spending using national Medicare data for 2012-15. While there was no association between out-of-network specialty care and ACO spending, each percentage-point increase in receipt of out-of-network primary care was associated with an increase of $10.79 in quarterly total ACO spending per beneficiary. When we broke down total spending by place of service, we found that out-of-network primary care was associated with higher spending in outpatient, skilled nursing facility, and emergency department settings, but not inpatient settings. Our findings suggest an opportunity for the Medicare program to realize substantial savings, if policy makers developed explicit incentives for beneficiaries to seek more of their primary care within network.

Cross-sectional study evaluating the association between integrated care and health-related quality of life (HRQOL) in Dutch primary care

OBJECTIVES

The aim of this study was to evaluate the association between integrated care and health-related quality of life (HRQOL) in a primary care practice population.

DESIGN

A cross-sectional survey study.

SETTING

Primary care practice population.

PARTICIPANTS

A sample (n=5562) of patients in two general practitioner practices in the Netherlands.

PRIMARY OUTCOME MEASURES

The Rainbow Model of Integrated Care Measurement Tool patient version and EQ-5D was used to assess integrated service delivery and HRQOL. The association between integrated care and HRQOL groups was analysed using multivariate logistic regression.

RESULTS

Overall, 933 respondents with a mean age of 62 participated (20% response rate) in this study. The multivariate analysis revealed that positive organisational coordination experiences were linked to better HRQOL (OR=1.87, 95% CI 1.18 to 2.95), and less anxiety and depression problems (OR=0.36, 95% CI 0.20 to 0.63). Unemployment was associated with a poor HRQOL (OR=0.15, 95% CI 0.08 to 0.28). Ageing was associated with more mobility (OR=1.06, 95% CI 1.04 to 1.09), self-care (OR=1.06, 95% CI 1.02 to 1.11), usual activity (OR=1.03, 95% CI 1.01 to 1.05) and pain problems (OR=1.02, 95% CI 1.01 to 1.04). Being married improved the overall HRQOL (OR=1.60, 95% CI 1.13 to 2.26) and decreased anxiety and depression (OR=0.47, 95% CI 0.31 to 0.72). Finally, females had a poor overall HRQOL (OR=1.67, 95% CI 0.48 to 0.93) and more pain and discomfort problems (OR=1.47, 95% CI 1.11 to 1.95).

CONCLUSION

This study shows for the first time that organisational coordination activities are positively associated with HROQL of adult patients in a primary care context, adding to the evidence of an association between integrated care and HRQOL. Also, unemployment, ageing and being female are accumulating risk factors that should be considered when designing integrated primary care programmes. Further research is needed to explore how various integration types relate to HRQOL for people in local communities.

Role of Nurse Practitioners in Caring for Patients With Complex Health Needs

OBJECTIVE

The objective of this study was to estimate trends in the percentage of Medicare beneficiaries cared for by nurse practitioners from 2012 to 2017, to characterize beneficiaries cared for by nurse practitioners in 2017, and to examine how the percentage of beneficiaries cared for by nurse practitioners varies by practice characteristics.

DESIGN

An observational study of 2012-2017 Medicare fee-for-service beneficiaries' ambulatory visits. We computed the percentage of beneficiaries with 1 or more ambulatory visits from nurse practitioners and the percentage of beneficiaries receiving the plurality of their ambulatory visits from a nurse practitioner versus a physician (ie, predominant provider). We compared beneficiary demographics, clinical characteristics, and utilization by the predominant provider. We then characterized the predominant provider by practice characteristics.

KEY RESULTS

In 2017, 28.9% of beneficiaries received any care from a nurse practitioner and 8.0% utilized nurse practitioners as their predominant provider-an increase from 4.4% in 2012. Among beneficiaries cared for by nurse practitioners in 2017, 25.9% had 3 or more chronic conditions compared with 20.8% of those cared for by physicians. Beneficiaries cared for in practices owned by health systems were more likely to have a nurse practitioner as their predominant provider compared with those attending practices that were independently owned (9.3% vs. 7.0%).

CONCLUSIONS

Nurse practitioners are caring for Medicare beneficiaries with complex needs at rates that match or exceed their physician colleagues. The growing role of nurse practitioners, especially in health care systems, warrants attention as organizations embark on payment and delivery reform.

Effects of Maryland's Affordable Care Act Medicaid Health Home Waiver on Quality of Cardiovascular Care Among People with Serious Mental Illness

BACKGROUND

Nineteen US states and D.C. have used the Affordable Care Act Medicaid health home waiver to create behavioral health home (BHH) programs for Medicaid beneficiaries with serious mental illness (SMI). BHH programs integrate physical healthcare management and coordination into specialty mental health programs. No studies have evaluated the effects of a BHH program created through the Affordable Care Act waiver on cardiovascular care quality among people with SMI.

OBJECTIVE

To study the effects of Maryland's Medicaid health home waiver BHH program, implemented October 1, 2013, on quality of cardiovascular care among individuals with SMI.

DESIGN

Retrospective cohort analysis using Maryland Medicaid administrative claims data from July 1, 2010, to September 30, 2016. We used marginal structural modeling with inverse probability of treatment weighting to account for censoring and potential time-dependent confounding.

PARTICIPANTS

Maryland Medicaid beneficiaries with diabetes or cardiovascular disease (CVD) participating in psychiatric rehabilitation programs, the setting in which BHHs were implemented. To qualify for psychiatric rehabilitation programs, individuals must have SMI. The analytic sample included BHH and non-BHH participants, N = 2605 with diabetes and N = 1899 with CVD.

MAIN MEASURES

Healthcare Effectiveness Data and Information Set (HEDIS) measures of cardiovascular care quality including annual receipt of diabetic eye and foot exams; HbA1c, diabetic nephropathy, and cholesterol testing; and statin therapy receipt and adherence among individuals with diabetes, as well as HEDIS measures of annual receipt of cholesterol testing and statin therapy and adherence among individuals with CVD.

KEY RESULTS

Relative to non-enrollment, enrollment in Maryland's BHH program was associated with increased likelihood of eye exam receipt among individuals with SMI and co-morbid diabetes, but no changes in other care quality measures.

CONCLUSIONS

Additional financing, infrastructure, and implementation supports may be needed to realize the full potential of Maryland's BHH to improve cardiovascular care for people with SMI.

Physician Work Hours and the Gender Pay Gap - Evidence from Primary Care

BACKGROUND

The gender gap in physician pay is often attributed in part to women working fewer hours than men, but evidence to date is limited by self-report and a lack of detail regarding clinical revenue and gender differences in practice style.

METHODS

Using national all-payer claims and data from electronic health records, we conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practices. Our primary independent variable was physician gender; outcomes included visit revenue, visit counts, days worked, and observed visit time (interval between the initiation and the termination of a visit). We created multivariable regression models at the year, day, and visit level after adjustment for characteristics of the primary care physicians (PCPs), patients, and types of visit and for practice fixed effects.

RESULTS

In 2017, female PCPs generated 10.9% less revenue from office visits than their male counterparts (-$39,143.2; 95% confidence interval [CI], -53,523.0 to -24,763.4) and conducted 10.8% fewer visits (-330.5 visits; 95% CI, -406.6 to -254.3) over 2.6% fewer clinical days (-5.3 days; 95% CI, -7.7 to -3.0), after adjustment for age, academic degree, specialty, and number of sessions worked per week, yet spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6). These results were consistent in subgroup analyses according to the gender and health status of the patients and the type and complexity of the visits.

CONCLUSIONS

Female PCPs generated less visit revenue than male colleagues in the same practices owing to a lower volume of visits, yet spent more time in direct patient care per visit, per day, and per year. (Funded in part by the Robert Wood Johnson Foundation.).

Some Aspects of Patient Experience Assessed by Practices Undergoing Patient-Centered Medical Home Transformation Are Measured by CAHPS, Others Are Not

BACKGROUND AND OBJECTIVES

Delivering care as a patient-centered medical home (PCMH) is being widely adopted across the United States by primary care practices to better meet patient needs. A key PCMH element is measuring patient experience for practice improvement. The National Committee for Quality Assurance (NCQA) PCMH recognition program requires practices to both measure patient experience and engage in continuous practice/quality improvement to attain PCMH recognition and then throughout full PCMH transformation. The NCQA recommends but does not require that practices administer the Consumer Assessment of Healthcare Providers and Systems (CAHPS) clinician and group patient experience survey (CG-CAHPS) plus 14 CAHPS PCMH items, known as the CAHPS PCMH survey. We examine aspects of patient experience measured by practices with a varying number of years on their journey of PCMH transformation.

METHODS

We randomly selected practices from the 2008-2017 NCQA directory of practices that had applied for PCMH recognition based on region, physician count, number of years and level of PCMH recognition, and use of the CG-CAHPS PCMH survey. We collected characteristics of the practices from practice leader(s) knowledgeable about the practice's PCMH history and patient experience data. We confirmed the patient experience surveys used during their PCMH history and requested copies of their non-CAHPS survey(s). For practices not administering the recommended CG-CAHPS survey (53/105 practices), we obtained and coded the content of their non-CAHPS surveys (68%; 36/53). We mapped the patient experience domains and specific measures to the CG-CAHPS survey (versions 2.0 and 3.0), CAHPS PCMH item set (versions 2.0 and 3.0), and the available CG-CAHPS supplemental items.

RESULTS

Whether or not practices administered the CG-CAHPS items, most of them addressed topics contained in the CG-CAHPS survey such as Access to care, Provider communication, Office staff helpfulness/courteousness, Care coordination, and Shared decision-making. The most common CAHPS measures included were Office staff helpfulness/courteousness and Provider communication. Common non-CAHPS measures included were Ease of scheduling, Being informed about delays, and Provider helpfulness/courteousness.

CONCLUSION

NCQA PCMH practices included CAHPS items on their patient experience surveys even if they did not administer the full CG-CAHPS survey or the recommended CAHPS PCMH survey. To enhance the usefulness of patient experience surveys for practices undergoing PCMH changes, additional CAHPS measures could be developed related to key areas of PCMH change, including expanded access to care (ie, after-hours and weekend visits, ease of scheduling, being informed about delays), use of shared decision-making, and improvements in provider communication (ie, the provider is courteous, communication by other clinical staff members with the patient). These additional measures would assist practice leaders in capturing the breadth and depth of their PCMH transformation and its influence on providing more patient-centered care. Developing such items would help standardize the measurement of changes related to patient experience during PCMH transformation. Research is needed to determine whether a CAHPS survey is the best source of this information.

Primary Care Office Visits For Acute Care Dropped Sharply In 2002-15, While ED Visits Increased Modestly

The traditional model of primary care practices as the main provider of care for acute illnesses is rapidly changing. Over the past two decades the growth in emergency department (ED) visits has spurred efforts to reduce "inappropriate" ED use. We examined a nationally representative sample of office and ED visits in the period 2002-15. We found a 12 percent increase in ED use (from 385 to 430 visits per 1,000 population), which was dwarfed by a decrease of nearly one-third in the rate of acute care visits to primary care practices (from 938 to 637 visits per 1,000 population). The decrease in primary care acute visits was also present among two vulnerable populations: Medicaid beneficiaries and adults ages sixty-five and older, either in Medicare or privately insured. As acute care delivery shifts away from primary care practices, there is a growing need for integration and coordination across an increasingly diverse spectrum of venues where patients seek care for acute illnesses.

Case-mix for assessing primary care value (CPCV)

Measuring primary care (PC) performance and designing payment systems that reward value rather than volume have been a great challenge due in large part to lack of reliable risk adjustment mechanisms pertinent to primary care. Using risk scores designed for total resource needs to assess PC performance or set PC payment rates is inadequate because high-cost patients may not have high needs in PC and vice versa. The greatest challenge in developing a risk algorithm for PC is that significant components of PC providers' workload are unobservable but needed in the modeling. In this study, we sought to overcome this challenge by analyzing 5,172,773 patients in the U.S. Veterans Affairs (VA) healthcare system to identify potential proxies of the unobservable PC workload. By combining the number of PC visits and prescription drug classes, we formed a proxy for the expected PC workload, which enabled us to develop a case-mix algorithm pertaining to primary care. The resultant algorithm with high explanatory power (R² = 0.702) is based on a publicly available patient classification system to account for patient comorbidities and thus can be used by other health systems to compare PC performance, workload, staffing levels, and to set more equitable payment rates.

Building a People-Centred Integrated Care Model in Urban China: A Qualitative Study of the Health Reform in Luohu

Introduction:

China has adopted a people-centred integrated care model to reform its severely hospital-centric and fragmented delivery system. As a template of this model in urban China, the Luohu Hospital Group has generated considerable public and academic interest to scale it up.

Methods:

Guided by a policy triangle framework, this qualitative study explored the context, actors, content, and process of founding the Luohu Hospital Group. Three semi-structured interviews and five focus groups were conducted among 35 key informants. Content analysis was used to analyse the data.

Results:

The reform in Luohu took place in a competitive health care market, based on the comprehensive health reform in Shenzhen. Under the strong leadership of the district government, the reform adopted comprehensive strategies to strengthen primary care and care coordination, improve the quality and efficiency of health care delivery, and promote population health. The reform achieved a high level of organisational integration but was still in the process of fulfilling professional and clinical integration.

Conclusions and discussion:

The establishment of the Luohu Hospital Group transformed the originally fragmented delivery system into a tightly integrated service delivery networks. Though valuable lessons have been generated, the reform and its impacts require ongoing monitoring.

Declining Use of Primary Care Among Commercially Insured Adults in the United States, 2008-2016

BACKGROUND

Primary care is known to improve outcomes and lower health care costs, prompting recent U.S. policy efforts to expand its role. Nonetheless, there is early evidence of a decline in per capita primary care visit rates, and little is understood about what is contributing to the decline.

OBJECTIVE

To describe primary care provider (PCP) visit trends among adults enrolled with a large, national, commercial insurer and assess factors underlying a potential decline in PCP visits.

DESIGN

Descriptive repeated cross-sectional study using 100% deidentified claims data from the insurer, 2008-2016. A 5% claims sample was used for Poisson regression models to quantify visit trends.

SETTING

National, population-based.

PARTICIPANTS

Adult health plan members aged 18 to 64 years.

MEASUREMENTS

PCP visit rates per 100 member-years.

RESULTS

In total, 142 million primary care visits among 94 million member-years were examined. Visits to PCPs declined by 24.2%, from 169.5 to 134.3 visits per 100 member-years, while the proportion of adults with no PCP visits in a given year rose from 38.1% to 46.4%. Rates of visits addressing low-acuity conditions decreased by 47.7% (95% CI, -48.1% to -47.3%). The decline was largest among the youngest adults (-27.6% [CI, -28.2% to -27.1%]), those without chronic conditions (-26.4% [CI, -26.7% to -26.1%]), and those living in the lowest-income areas (-31.4% [CI, -31.8% to -30.9%]). Out-of-pocket cost per problem-based visit rose by $9.4 (31.5%). Visit rates to specialists remained stable (-0.08% [CI, -0.56% to 0.40%]), and visits to alternative venues, such as urgent care clinics, increased by 46.9% (CI, 45.8% to 48.1%).

LIMITATION

Data were limited to a single commercial insurer and did not capture nonbilled clinician-patient interactions.

CONCLUSION

Commercially insured adults have been visiting PCPs less often, and nearly one half had no PCP visits in a given year by 2016. Our results suggest that this decline may be explained by decreased real or perceived visit needs, financial deterrents, and use of alternative sources of care.

PRIMARY FUNDING SOURCE

None.

National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015

PURPOSE

Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed.

METHODS

We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR).

RESULTS

Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3).

CONCLUSION

From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care.

Evidence and Implications Behind a National Decline in Primary Care Visits

Primary care is the foundation of the health care system and the basis for new payment and delivery reforms in the USA. Yet since 2008, primary care visit rates dropped by 6-25% across a range of populations in five sources of national survey and administrative data. We hypothesize three likely mechanisms behind the decline: decreases in patients' ability, need, or desire to seek primary care; changes in primary care practice such as greater use of teams and non-face-to-face care; and replacement of in-person primary care visits with alternatives such as specialist, retail clinic, and commercial telemedicine visits. These mechanisms require further investigation. In the meantime, the trend prompts us to optimize the primary care visit and embrace the growth of alternatives while preserving the fundamental benefits of primary care.

Does Employee Safety Matter for Patients Too? Employee Safety Climate and Patient Safety Culture in Health Care

OBJECTIVE

We examined relationships between employee safety climate and patient safety culture. Because employee safety may be a precondition for the development of patient safety, we hypothesized that employee safety culture would be strongly and positively related to patient safety culture.

METHODS

An employee safety climate survey was administered in 2010 and assessed employees' views and experiences of safety for employees. The patient safety survey administered in 2011 assessed the safety culture for patients. We performed Pearson correlations and multiple regression analysis to examine the relationships between a composite measure of employee safety with subdimensions of patient safety culture. The regression models controlled for size, geographic characteristics, and teaching affiliation. Analyses were conducted at the group level using data from 132 medical centers.

RESULTS

Higher employee safety climate composite scores were positively associated with all 9 patient safety culture measures examined. Standardized multivariate regression coefficients ranged from 0.44 to 0.64.

CONCLUSIONS

Medical facilities where staff have more positive perceptions of health care workplace safety climate tended to have more positive assessments of patient safety culture. This suggests that patient safety culture and employee safety climate could be mutually reinforcing, such that investments and improvements in one domain positively impacts the other. Further research is needed to better understand the nexus between health care employee and patient safety to generalize and act upon findings.

Health Information Technology and Accountable Care Organizations: A Systematic Review and Future Directions

Background:

Since the inception of Accountable Care Organizations (ACOs), many have acknowledged the potential synergy between ACOs and health information technology (IT) in meeting quality and cost goals.

Objective:

We conducted a systematic review of the literature in order to describe what research has been conducted at the intersection of health IT and ACOs and identify directions for future research.

Methods:

We identified empirical studies discussing the use of health IT via PubMed search with subsequent snowball reference review. The type of health IT, how health IT was included in the study, use of theory, population, and findings were extracted from each study.

Results:

Our search resulted in 32 studies describing the intersection of health IT and ACOs, mainly in the form of electronic health records and health information exchange. Studies were divided into three streams by purpose; those that considered health IT as a factor for ACO participation, health IT use by current ACOs, and ACO performance as a function of health IT capabilities. Although most studies found a positive association between health IT and ACO participation, studies that address the performance of ACOs in terms of their health IT capabilities show more mixed results.

Conclusions:

In order to better understand this emerging relationship between health IT and ACO performance, we propose future research should consider more quasi-experimental studies, the use of theory, and merging health, quality, cost, and health IT use data across ACO member organizations.

Association Between Specialist Office Visits and Health Expenditures in Accountable Care Organizations

IMPORTANCE

Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective.

OBJECTIVE

To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists.

EXPOSURES

Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater.

MAIN OUTCOMES AND MEASURES

The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders.

RESULTS

In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion.

CONCLUSIONS AND RELEVANCE

These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.

Geographic Expansion of Federally Qualified Health Centers 2007-2014

PURPOSE

Federally Qualified Health Centers (FQHCs), which were expanded under the Affordable Care Act, are federally funded health centers that aim to improve access to primary care in underserved areas. With continued federal support, the number of FQHCs in the United States has increased >80% within a decade. However, the expansion patterns and their impact on the population served are unknown.

METHODS

A pre (2007)-post (2014) study of FQHC locations. FQHC locations were identified from the Provider of Services Files then linked to primary care service areas (PCSAs), which represent the service markets that FQHCs served. Road-based travel time was estimated from each 2007 FQHC to the nearest new FQHC as an indicator of geographic expansion in access. PCSA-level characteristics were used to compare 2007 and 2014 FQHC service markets.

FINDINGS

Between 2007 and 2014, there was greater expansion in the number of FQHCs (3,489 vs 6,376; 82.7%) than in the number of service markets (1,835 vs 2,695; 46.9%). Nearly half of 2007 FQHCs (47%) had at least one new FQHC within 30 minutes travel time. Most newly certified FQHCs (81%) were located in urban areas. Compared to 2007 service markets, the new 2014 markets (N = 174) were much less likely to be in areas with >20% of the population below poverty (31.4% vs 14.9%, P < .001).

CONCLUSIONS

The latest expansion of FQHCs was less likely to be in rural or high poverty areas, suggesting the impact of expansion may have limitations in improving access to care among the most financially disadvantaged populations.

Toward a Unified Integration Approach: Uniting Diverse Primary Care Strategies Under the Primary Care Behavioral Health (PCBH) Model

Primary care continues to be at the center of health care transformation. The Primary Care Behavioral Health (PCBH) model of service delivery includes patient-centered care delivery strategies that can improve clinical outcomes, cost, and patient and primary care provider satisfaction with services. This article reviews the link between the PCBH model of service delivery and health care services quality improvement, and provides guidance for initiating PCBH model clinical pathways for patients facing depression, chronic pain, alcohol misuse, obesity, insomnia, and social barriers to health.

Factors That Influence Job Choice at the Time of Graduation for Physician Assistant Students

Research and data analysis show that there is a shortage of primary care providers throughout the United States. Physician assistants (PAs) play an important role in health care delivery; however, the percentage of PAs practicing in primary care has dramatically decreased in the past 15 years. The purpose of this study was to identify potential factors that influence PA students' first job choice following graduation from a PA program to determine whether they have a relationship to the choosing of primary care. The 2016 End of Program Survey data were analyzed using a multinominal logistic regression to determine what factors influenced PA students' selections of primary care as their first job choice: individual factors, program factors, and external factors. Of the 3038 subjects, 269 (8.9%) accepted a job in primary care, 847 (27.9%) accepted a specialty job, and 1922 (63.3%) did not accept a job. When comparing no job accepted versus primary care job choice, marital status and racial/ethnic differences influenced first job choice. Financial factors were also found to be significant predictors. In the second model, comparing specialty versus primary care job choice, marital status influenced first job choice along with financial factors. In addition, one program variable (moderate clinical rotation experience) was found to be statistically significant in the model of specialty versus primary care job choice. Financial factors were found to be the greatest predictor in first job choice. Focusing on policy to help reduce student debt and increase reimbursement rates could help increase the number of students choosing primary care.

EMR Adaptations to Support the Identification and Risk Stratification of Children with Special Health Care Needs in the Medical Home

Introduction Children with special health care needs (CSHCN) are a high risk population with complex medical issues and needs. It is challenging to care for them in a busy, pediatric practice without understanding how many exist and how best to allocate resources. EMRs can be adapted to develop registries and stratify patients to promote population health management. Methods Adaptations were made to the EMR in September 2013 to capture CSHCN and the associated risk level during well-child visits prospectively. All physicians were trained on the definition of CSHCN and on risk stratification levels 1, 2, 3A and 3B. An analysis using one-way ANOVA for children ages 0-21, seen between September 1, 2011 and August 31, 2015, who were identified and stratified after September 2013, was conducted to determine utilization patterns on hospital admissions, emergency department (ED), subspecialty, and primary care visits. Results A total of 4687 CSHCN were identified during the study period. Of the CSHCN, 45% were Level 1, 41% Level 2, 7% 3A and 7% 3B. There were significant differences in utilization across the tiers of CSHCN with the highest level of stratification (3B) demonstrating the most hospital admissions and primary care visits. Level 3B and level 3A (unstable) had significantly more ED visits. Additionally, as tiers increased from level 1 to 3B there was an increase in subspecialty provider utilization (p < 0.0001). Discussion The EMR adaptations developed for CSHCN identified the expected number of CSHCN and predicted utilization patterns across primary, subspecialty, ED and in-patient care.

Facilitating primary care provider use in a patient-centered medical home intervention study for chronic hemodialysis patients

Patients with chronic kidney disease have a high disease burand may benefit from primary care services and care coord A medical home model with direct access to primary care services is one approach that may address this need, yet has not been examined. As a substudy of the Patient-Centered Outcomes Research Institute (PCORI) patient-centered medical home for kidney disease (PCMH-KD) health system intervention study, we examined the uptake of free primary care physician (PCP) services. The PCORI PCMH-KD study was an initial step toward integrating PCPs, a nurse coordinator, a pharmacist, and community health workers (CHWs) within the health care delivery team. Adult chronic hemodialysis (CHD) at two urban dialysis centers were enrolled in the intervention. We examined trends and factors associated with the use of the PCMH-KD PCP among two groups of patients based on their report of having a regular physician for at least six months (established-PCP) or not (no-PCP). Of the 173 enrolled patients, 91 (53%) patients had at least one visit with the PCMH-KD PCP. The rate of visits was higher in those in the no-PCP group compared with those in the established-PCP group (62% vs. 41%, respectively). Having more visits with the CHW was positively associated with having a visit with the PCMH-KD PCPs for both groups. Embedded CHWs within the care team played a role in facilithe uptake of PCMH-KD PCP. Lessons from this health system intervention can inform future approaches on the integration of PCPs and care coordination for CHD patients.

Coordinating primary care services: A case of policy layering

In this paper, we discuss the processes of policy layering as they relate to health care reform. We focus on efforts to achieve systems of coordinated primary care, and demonstrate that material change can be achieved through processes of incremental policy layering. Such processes also have a high potential for unintended consequences. Thus, we propose new principles of 'smart' policy layering to guide decision-makers to do incrementalism better. We then apply these principles to recent primary care reforms in Ontario, Canada. This paper conceptualizes 'smart' policy layering as a mechanism to achieve productive policy change in contexts with strong institutional barriers to reform.

Utilization of High-Cost Interventions for Targeted Clinical Conditions During the Early Stages of ACO Development in a Commercially Insured Population

This study compared utilization patterns of high-cost services and medications for patients receiving care from Accountable Care Organization (ACO)-participating physicians and those receiving care from non-ACO physicians during the initial phases of ACO development in a commercially insured environment. Patients ≥18 years (≥40 years for chronic obstructive pulmonary disease [COPD]) with prevalent rheumatoid arthritis, inflammatory bowel disease, multiple sclerosis, type 2 diabetes, COPD, or chronic low back pain between January 1, 2012, and August 31, 2014 were identified in the HealthCore Integrated Research Database^SM. Patients were assigned to the ACO cohort if their primary treating physician was contracted to the health plan through an ACO agreement. Each clinical condition was stratified for severity of illness. Cohort utilization patterns were compared for the 12-month period following the index encounter. The primary outcome measures show that there was no statistically significant utilization difference between the ACO and non-ACO cohorts for 90% of the 82 comparisons made. It is expected that some measures will achieve significant difference simply because of having this many comparisons, but no clear pattern was identified. This study did not observe statistically significant differences in utilization of high-cost services and medications between ACO and non-ACO cohorts with limited experience in the ACO model. Future analyses with longer study durations, at later stages of ACO development, tracking a more granular level of physician organizational structure, and with designs that integrate clinical and administrative data are essential to better understand the impact of payment innovation strategies using an ACO structure.

Formalisation and subordination: a contingency theory approach to optimising primary care teams

OBJECTIVE

While there is consensus on the need to strengthen primary care capacities to improve healthcare systems' performance and sustainability, there is only limited evidence on the best way to organise primary care teams. In this article, we use a conceptual framework derived from contingency theory to analyse the structures and process optimisation of multiprofessional primary care teams.

DESIGN

We focus specifically on inter-relationships between three dimensions: team size, formalisation of care processes and nurse autonomy. Interview-based qualitative data for each of these three dimensions were converted into ordinal scores. Data came from eight pilot sites in Quebec (Canada).

RESULTS

We found a positive association between team size and formalisation (correlation score 0.55) and a negative covariation (correlation score -0.64) between care process formalisation and nurses' autonomy/subordination. Despite the study being exploratory in nature, such relationships validate the idea that these dimensions should be analysed conjointly and are coherent with our suggestion that using a framework derived from a contingency approach makes sense.

CONCLUSIONS

The results provide insights about the structural design of nurse-intensive primary care teams. Non-physicians' professional autonomy is likely to be higher in smaller teams. Likewise, a primary care team that aims to increase nurses' and other non-physicians' professional autonomy should be careful about the extent to which it formalises its processes.

Organizational Influences on Time Pressure Stressors and Potential Patient Consequences in Primary Care

BACKGROUND

Primary care teams face daily time pressures both during patient encounters and outside of appointments.

OBJECTIVES

We theorize 2 types of time pressure, and test hypotheses about organizational determinants and patient consequences of time pressure.

RESEARCH DESIGN

Cross-sectional, observational analysis of data from concurrent surveys of care team members and their patients.

SUBJECTS

Patients (n=1291 respondents, 73.5% response rate) with diabetes and/or coronary artery disease established with practice teams (n=353 respondents, 84% response rate) at 16 primary care sites, randomly selected from 2 Accountable Care Organizations.

MEASURES AND ANALYSIS

We measured team member perceptions of 2 potentially distinct time pressure constructs: (1) encounter-level, from 7 questions about likelihood that time pressure results in missing patient management opportunities; and (2) practice-level, using practice atmosphere rating from calm to chaotic. The Patient Assessment of Chronic Illness Care (PACIC-11) instrument measured patient-reported experience. Multivariate logistic regression models examined organizational predictors of each time pressure type, and hierarchical models examined time pressure predictors of patient-reported experiences.

RESULTS

Encounter-level and practice-level time pressure measures were not correlated, nor predicted by the same organizational variables, supporting the hypothesis of two distinct time pressure constructs. More encounter-level time pressure was most strongly associated with less health information technology capability (odds ratio, 0.33; P<0.01). Greater practice-level time pressure (chaos) was associated with lower PACIC-11 scores (odds ratio, 0.74; P<0.01).

CONCLUSIONS

Different organizational factors are associated with each forms of time pressure. Potential consequences for patients are missed opportunities in patient care and inadequate chronic care support.

Patient-centered medical home care access among adults with chronic conditions: National Estimates from the medical expenditure panel survey

BACKGROUND

The Patient-Centered Medical Home (PCMH) model is a coordinated-care model that has served as a means to improve several chronic disease outcomes and reduce management costs. However, access to PCMH has not been explored among adults suffering from chronic conditions in the United States. Therefore, the aim of this study was to describe the changes in receiving PCMH among adults suffering from chronic conditions that occurred from 2010 through 2015 and to identify predisposing, enabling, and need factors associated with receiving a PCMH.

METHODS

A cross-sectional analysis was conducted for adults with chronic conditions, using data from the 2010-2015 Medical Expenditure Panel Surveys (MEPS). Most common chronic conditions in the United States were identified by using the most recent data published by the Agency for Healthcare Research and Quality (AHRQ). The definition established by the AHRQ was used as the basis to determine whether respondents had access to PCMH. Multivariate logistic regression analyses were conducted to detect the association between the different variables and access to PCMH care.

RESULTS

A total of 20,403 patients with chronic conditions were identified, representing 213.7 million U.S. lives. Approximately 19.7% of the patients were categorized as the PCMH group at baseline who met all the PCMH criteria defined in this paper. Overall, the percentage of adults with chronic conditions who received a PCMH decreased from 22.3% in 2010 to 17.8% in 2015. The multivariate analyses revealed that several subgroups, including individuals aged 66 and older, separated, insured by public insurance or uninsured, from low-income families, residing in the South or the West, and with poor health, were less likely to have access to PCMH.

CONCLUSION

Our findings showed strong insufficiencies in access to a PCMH between 2010 and 2015, potentially driven by many factors. Thus, more resources and efforts need to be devoted to reducing the barriers to PCMH care which may improve the overall health of Americans with chronic conditions.

The Association Between Hospital ACO Participation and Readmission Rates

EXECUTIVE SUMMARY

Accountable care organizations (ACOs) were established as part of the Affordable Care Act to reduce costs, improve the patient experience, and increase the quality of care. While previous studies have examined the quality, costs, and patient experience among ACOs, the relationship between hospitals' ACO participation and its effects on hospitals' performance have been incompletely characterized. The main purpose of this study is to measure the association between hospitals' participation in Medicare Pioneer and Shared Savings Program (SSP) ACOs and readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. We employed a cross-sectional design using hospital readmission data from Hospital Compare, hospital characteristics data from the American Hospital Association Annual Survey, and market environmental data from Area Health Resource Files. We employed a descriptive analysis and linear regressions to examine how ACO participation is associated with readmission rates in these three conditions.Overall, we found that SSP ACO participation is significantly associated with a decrease in the HF readmission rate (β = 0.320, p < .05), while Pioneer ACO participation is not associated with a decrease in the HF readmission rate. In addition, we found no evidence that Pioneer ACO or SSP ACO participation is associated with reduced readmission rates for AMI or pneumonia. This study concluded that Medicare ACO programs have limited effects on readmission rates. Policy makers should consider adjusting the accountable care model to improve the quality of care.

Implementing Lean in Academic Primary Care

BACKGROUND

Lean is emerging as a quality improvement (QI) strategy in health care, but there has been minimal adoption in primary care teaching practices. This study describes a strategy for implementing Lean in an academic family medicine center and provides a formative assessment of this approach.

METHODS

A case study of the University of North Carolina Family Medicine Center that used the Consolidated Framework for Implementation Research to guide a formative evaluation. The implementation strategy included partnering with Lean content experts and creating a leadership team; planning and completing QI events and Lean training modules; and evaluating and reporting activities related to QI and training.

RESULTS

During the initial period of Lean implementation, there was (1) minimal to no change in the quality of care as determined by the Preventive Care Index (46-48); (2) a decrease patient appointment cycle time from 89 minutes to 65 minutes; (3) an increase in overall practice productivity from $8144 to $9160; (4) a decrease in patient satisfaction from 94% to 91%; and (5) an increase in monthly visit volume from 4112 to 5076.

CONCLUSION

Lean had an uneven effect on QI in an academic primary care practice during the first year of implementation.

A tale of four practices

Purpose The Patient-Centered Medical Home (PCMH) has become a dominant model of primary care re-design. This transformation presents a challenge to many care delivery organizations. The purpose of this paper is to describe attributes shaping successful and unsuccessful practice transformation within four medical practice groups. Design/methodology/approach As part of a larger study of 25 practices transitioning into a PCMH, the current study focused on diabetes care and identified high- and low-improvement medical practices in terms of quantitative patient measures of glycosylated hemoglobin and qualitative assessments of practice performance. A subset of the top two high-improvement and bottom two low-improvement practices were identified as comparison groups. Semi-structured interviews were conducted with diverse personnel at these practices to investigate their experiences with practice transformation and data were analyzed using analytic induction. Findings Results show a variety of key attributes facilitating more successful PCMH transformation, such as empanelment, shared goals and regular meetings, and a clear understanding of PCMH transformation purposes, goals, and benefits, providing care/case management services, and facilitating patient reminders. Several barriers also exist to successful transformation, such as low levels of resources to handle financial expense, lack of understanding PCMH transformation purposes, goals, and benefits, inadequate training and management of technology, and low team cohesion. Originality/value Few studies qualitatively compare and contrast high and low performing practices to illuminate the experience of practice transformation. These findings highlight the experience of organizational members and their challenges in practice transformation while providing quality diabetes care.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Adapting to a Shifting Health Care Landscape: Illinois Breast and Cervical Cancer Program Lead Agencies' Perspectives

Understanding how safety net programs adapt to systemic health care changes is pivotal for creating feasible recommendations for policy implementation. This study characterizes perspectives of Lead Agency (LA) coordinators of the Illinois Breast and Cervical Cancer Program (IBCCP) in response to sociopolitical changes at state and national levels. Our cross-sectional study included 29 semistructured telephone interviews between December 2015 and January 2016. Respondents indicated some changes in the priority population served, changes in referrals and clinical services, and, a continued commitment to IBCCP. Our findings suggest that IBCCP and other safety net programs will need to be flexible to meet the ongoing needs of historically vulnerable populations in a complex, shifting environment. Implications for public health practice and policy include the need to ensure that program personnel are aware of evidence-based strategies to reach different priority populations and are kept abreast of organizational and system changes that may affect referral patterns as well as the need to educate health care providers working with safety net programs about changes in the delivery and coordination of services.