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Levin JS, Komanduri S, Whaley C. Association between hospital-physician vertical integration and medication adherence rates. Health Serv Res 2023; 58:356-364. [PMID: 36272112 PMCID: PMC10012217 DOI: 10.1111/1475-6773.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To test the association between vertical integration of primary care providers (PCPs) and adherence rates for anti-diabetics, renin angiotensin system antagonists (RASA), and statins. DATA SOURCES Medicare Part B outpatient fee-for-service claims and Medicare Part D event data from 2014 to 2017. STUDY DESIGN We estimated difference-in-differences regressions, comparing changes in adherence among patients with PCPs who converted from independent to integrated to changes among patients whose PCPs remained independent or integrated during the study period. To test for heterogenous impacts by patient demographics, we estimated triple difference regressions that included additional interaction terms by comorbidity rates, age group, and race/ethnicity. EXTRACTION METHODS We extracted Medicare claims for adults with continuous enrollment in Parts B and D during the study period. PRINCIPAL FINDINGS The proportion of patients who had a vertically integrated PCP increased by approximately 23% over the study period. Changes in adherence did not differ significantly between patients based on whether their PCP became integrated (Statins: 0.18, 95% CI -0.13, 0.49; RASA: -0.13, 95% CI -0.46, 0.19; Anti-Diabetics: -0.20, 95% CI -0.78, 0.38). Among patients with PCPs who became integrated, there were significant decreases in adherence for patients who were Black, Asian, Hispanic, or Native American, above 80 years old, and had greater comorbidities for all three classes. CONCLUSIONS While there were no average changes in adherence following vertical integration of PCPs, health equity worsened, with significant declines in adherence for Black, Asian, Hispanic, and Native American patients, patients over 80 years old, and patients with greater comorbidities. These findings suggest that integration may reduce clinicians' incentives to compete based on the quality of care delivered. Given the price increases associated with integration, integration may be a net welfare loss.
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Affiliation(s)
| | - Swad Komanduri
- RAND Health Care, RAND Corporation, Santa Monica, California, USA
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2
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Impact of integrated behavioral health services on adherence to long-acting injectable antipsychotics. JOURNAL OF INTEGRATED CARE 2022. [DOI: 10.1108/jica-08-2021-0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeIntegrated health care occurs when specialty and general care providers work together to address both the physical and mental health needs of their patients. The Substance Abuse and Mental Health Services Administration model of integration is broken into six levels of coordinated, co-located and integrated care. Our institution offers both co-located and integrated care among eight clinic sites. The care team is typically composed of the primary care provider, nurse and medical assistant, but other professionals may be introduced based on the patient’s medical and psychiatric conditions. The purpose of this prospective, quality improvement study was to compare the rates of adherence to long-acting injectable antipsychotics (LAIAs) between both types of integrated primary care settings at our institution. The comparison of the two settings sought to determine which environment provides improved outcomes for patients with serious psychiatric illnesses. Additionally, we aimed to assess the quality of medication-related monitoring and care team composition between care settings, and the ability of pharmacists to deliver interprofessional care team training and education on LAI use in clinical practice.Design/methodology/approachSubjects were identified and included in the study if they had received primary care services from our institution within the previous 12 months. Patient demographic and laboratory variables were collected at baseline and when clinically indicated. The rates of adherence between care settings were assessed at intervals that align with the medication’s administration schedule (e.g. every four weeks). Medication-related monitoring parameters were collected at baseline and when clinically indicated. The interprofessional care team completed Likert scale surveys to evaluate the pharmacist’s LAIA education and training.FindingsThere was not a statistically significant difference detected between integrated primary care settings on the rates of adherence to LAIAs. Additionally, there was not a statistically significant difference between rates of adherence to medication-related monitoring parameters or the effect of the patient treatment team composition. There was a statistically significant difference between pre- and post-session survey scores following interprofessional education and training provided by a pharmacist.Originality/valueBecause overall rates of adherence were low, both primary care settings were found to be equivalent. Our study may have been underpowered to detect a difference in the primary endpoint because of the small sample size. However, our study demonstrates that interprofessional education and training may lend itself to changes in practice, which is evident by the clinically significant relative increase in adherence. The Henry J. Austin Health Center network will be implementing a standard operating procedure regarding LAIA management within the primary care setting. Further studies are needed to assess a larger number of patients between both types of primary care settings, as well as the impact of the clinical psychiatric pharmacist as a member of the treatment team.
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3
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Faruqui SHA, Alaeddini A, Wang J, Fisher-Hoch SP, McCormick JB. Dynamic Functional Continuous Time Bayesian Networks for Prediction and Monitoring of the Impact of Patients' Modifiable Lifestyle Behaviors on the Emergence of Multiple Chronic Conditions. IEEE ACCESS : PRACTICAL INNOVATIONS, OPEN SOLUTIONS 2021; 9:169092-169106. [PMID: 35601689 PMCID: PMC9121781 DOI: 10.1109/access.2021.3136618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
More than a quarter of all Americans are estimated to have multiple chronic conditions (MCC). It is known that shared modifiable lifestyle behaviors account for many common MCC. What is not precisely known is the dynamic effect of changes in lifestyle behaviors on the trajectories of MCC emergence. This paper proposes dynamic functional continuous time Bayesian networks to effectively formulate the dynamic effect of patients' modifiable lifestyle behaviors and their interaction with non-modifiable demographics and preexisting conditions on the emergence of MCC. The proposed method considers the parameters of the conditional dependencies of MCC as a nonlinear state-space model and develops an extended Kalman filter to capture the dynamics of the modifiable risk factors on the MCC evolution. It also develops a tensor-based control chart based on the integration of multilinear principal component analysis and multivariate exponentially weighted moving average chart to monitor the effect of changes in the modifiable risk factors on the risk of new MCC. We validate the proposed method based on a combination of simulation and a real dataset of 385 patients from the Cameron County Hispanic Cohort. The dataset examines the emergence of 5 chronic conditions (Diabetes, Obesity, Cognitive Impairment, Hyperlipidemia, Hypertension) based on 4 modifiable lifestyle behaviors representing (Diet, Exercise, Smoking Habits, Drinking Habits) and 3 non-modifiable demographic risk factors (Age, Gender, Education). For the simulated study, the proposed algorithm shows a run-length of 4 samples (4 months) to identify behavioral changes with significant impacts on the risk of new MCC. For the real data study, the proposed algorithm shows a run-length of one sample (one year) to identify behavioral changes with significant impacts on the risk of new MCC. The results demonstrate the sensitivity of the proposed methodology for dynamic prediction and monitoring of the risk of MCC emergence in individual patients.
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Affiliation(s)
- Syed Hasib Akhter Faruqui
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Adel Alaeddini
- Department of Mechanical Engineering, The University of Texas at San Antonio, San Antonio, TX 78249, USA
| | - Jing Wang
- College of Nursing, Florida State University, Tallahassee, FL 32306, USA
| | - Susan P Fisher-Hoch
- School of Public Health, The University of Texas Health Houston, Brownsville, TX 78520, USA
| | - Joseph B McCormick
- School of Public Health, The University of Texas Health Houston, Brownsville, TX 78520, USA
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4
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McGinty EE, Presskreischer R, Breslau J, Brown JD, Domino ME, Druss BG, Horvitz-Lennon M, Murphy KA, Pincus HA, Daumit GL. Improving Physical Health Among People With Serious Mental Illness: The Role of the Specialty Mental Health Sector. Psychiatr Serv 2021; 72:1301-1310. [PMID: 34074150 PMCID: PMC8570967 DOI: 10.1176/appi.ps.202000768] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Rachel Presskreischer
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Joshua Breslau
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Jonathan D Brown
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Marisa Elena Domino
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Benjamin G Druss
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Marcela Horvitz-Lennon
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Karly A Murphy
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Harold Alan Pincus
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
| | - Gail L Daumit
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore (McGinty, Presskreischer); RAND Corporation, Pittsburgh (Breslau) and Boston (Horvitz-Lennon); Mathematica, Washington, D.C. (Brown); Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill (Domino); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Druss); Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore (Murphy, Daumit); Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York City (Pincus)
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5
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Fakeye OA, Khanna N, Hsu YJ, Marsteller JA. Impact of a Statewide Multi-Payer Patient-Centered Medical Home Program on Antihypertensive Medication Adherence. Popul Health Manag 2021; 25:309-316. [PMID: 34609933 DOI: 10.1089/pop.2021.0172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Evidence suggests that the patient-centered medical home (PCMH) model of primary care improves management of chronic disease, but there is limited research contrasting this model's effect when financed by a single payer versus multiple payers, and among patients with different types of health insurance. This study evaluates the impact of a statewide medical home demonstration, the Maryland Multi-Payer PCMH Program (MMPP), on adherence to antihypertensive medication therapy relative to non-PCMH primary care and to the PCMH model when financed by a single payer. The authors used a difference-in-differences analytic design to analyze changes in medication possession ratio for antihypertensive medications among Medicaid-insured and privately insured non-elderly adult patients attributed to primary care practices in the MMPP ("multi-payer PCMHs"), medical homes in Maryland that participated in a regional PCMH program funded by a single private payer ("single-payer PCMHs"), and non-PCMH practices in Maryland. Comparison sites were matched to multi-payer PCMHs using propensity scores based on practice characteristics, location, and aggregated provider characteristics. Multi-payer PCMHs performed better on antihypertensive medication adherence for both Medicaid-insured and privately insured patients relative to single-payer PCMHs. Statistically significant effects were not observed consistently until the second year of the demonstration. There were negligible differences in outcome trends between multi-payer medical homes and matched non-PCMH practices. Findings indicate that health care delivery innovations may yield superior population health outcomes under multi-payer financing compared to when such initiatives are financed by a single payer.
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Affiliation(s)
- Oludolapo A Fakeye
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Niharika Khanna
- Department of Family and Community Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jill A Marsteller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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6
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Foley L, Larkin J, Lombard-Vance R, Murphy AW, Hynes L, Galvin E, Molloy GJ. Prevalence and predictors of medication non-adherence among people living with multimorbidity: a systematic review and meta-analysis. BMJ Open 2021; 11:e044987. [PMID: 34475141 PMCID: PMC8413882 DOI: 10.1136/bmjopen-2020-044987] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This systematic review aimed to describe medication non-adherence among people living with multimorbidity according to the current literature, and synthesise predictors of non-adherence in this population. METHODS A systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses. PubMed, EMBASE, CINAHL and PsycINFO were searched for relevant articles published in English language between January 2009 and April 2019. Quantitative studies reporting medication non-adherence and/or predictors of non-adherence among people with two or more chronic conditions were included in the review. A meta-analysis was conducted with a subgroup of studies that used an inclusive definition of multimorbidity to recruit participants, rather than seeking people with specific conditions. Remaining studies reporting prevalence and predictors of non-adherence were narratively synthesised. RESULTS The database search produced 10 998 records and a further 75 were identified through other sources. Following full-text screening, 178 studies were included in the review. The range of reported non-adherence differed by measurement method, at 76.5% for self-report, 69.4% for pharmacy data, and 44.1% for electronic monitoring. A meta-analysis was conducted with eight studies (n=8949) that used an inclusive definition of multimorbidity to recruit participants. The pooled prevalence of non-adherence was 42.6% (95% CI: 34.0 - 51.3%, k=8, I2=97%, p<0.01). The overall range of non-adherence was 7.0%-83.5%. Frequently reported correlates of non-adherence included previous non-adherence and treatment-related beliefs. CONCLUSIONS The review identified a heterogeneous literature in terms of conditions studied, and definitions and measures of non-adherence used. Results suggest that future attempts to improve adherence among people with multimorbidity should determine for which conditions individuals require most support. The variable levels of medication non-adherence highlight the need for more attention to be paid by healthcare providers to the impact of multimorbidity on chronic disease self-management. PROSPERO REGISTRATION NUMBER CRD42019133849.
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Affiliation(s)
- Louise Foley
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - James Larkin
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Richard Lombard-Vance
- Department of Psychology, National University of Ireland Maynooth, Maynooth, Ireland
| | - Andrew W Murphy
- Discipline of General Practice, National University of Ireland Galway, Galway, Ireland
- HRB Primary Care Clinical Trials Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Lisa Hynes
- Health Programmes, Croà Heart & Stroke Centre, Galway, Ireland
| | - Emer Galvin
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerard J Molloy
- School of Psychology, National University of Ireland Galway, Galway, Ireland
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Swietek KE, Domino ME, Grove LR, Beadles C, Ellis AR, Farley JF, Jackson C, Lichstein JC, DuBard CA. Duration of medical home participation and quality of care for patients with chronic conditions. Health Serv Res 2021; 56 Suppl 1:1069-1079. [DOI: 10.1111/1475-6773.13710] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/23/2021] [Accepted: 06/25/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | - Marisa Elena Domino
- Department of Health Policy and Management, The Gillings School of Global Public Health The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
- Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Lexie R. Grove
- Department of Health Policy and Management, The Gillings School of Global Public Health The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Chris Beadles
- Health Care Quality and Outcomes Program RTI International Research Triangle Park North Carolina USA
| | - Alan R. Ellis
- School of Social Work North Carolina State University Raleigh North Carolina USA
| | - Joel F. Farley
- College of Pharmacy University of Minnesota Minneapolis Minnesota USA
| | - Carlos Jackson
- Community Care of North Carolina, Inc. Cary North Carolina USA
| | - Jesse C. Lichstein
- Department of Health Policy and Management, The Gillings School of Global Public Health The University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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8
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Schuttner L, Wong ES, Rosland AM, Nelson K, Reddy A. Association of the Patient-Centered Medical Home Implementation with Chronic Disease Quality in Patients with Multimorbidity. J Gen Intern Med 2020; 35:2932-2938. [PMID: 32767035 PMCID: PMC7572962 DOI: 10.1007/s11606-020-06076-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) was established in part to improve chronic disease management, yet evidence is limited for effects on patients with multimorbidity. OBJECTIVE To examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014. DESIGN Retrospective cohort. PATIENTS 318,764 multimorbid (> 3 chronic diseases) patients receiving care in 917 clinics. MAIN MEASURES PCMH implementation was measured using the PACT Implementation Progress Index (PI2) for clinics in 2012. The PI2 is a validated composite measure of administrative and survey data with higher scores associated with greater care quality. Quality outcomes from 2013 to 2014 were assessed from External Peer Review Program (EPRP) metrics. Outcomes included preventative care, chronic disease management, and mental health and substance use metrics. We used generalized estimating equations to model associations adjusting for patient and clinic characteristics. We also examined associations for a subgroup with > 5 chronic diseases. KEY RESULTS For one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics (diabetic glycemic control, P < 0.001; lipid control in ischemic heart disease, P = 0.02) among patients with > 5 chronic diseases. CONCLUSIONS Multimorbid patients engaged in care from clinics with higher PCMH implementation received higher quality care across several quality domains, but this association was reduced in patients with > 5 chronic diseases.
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Affiliation(s)
- Linnaea Schuttner
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA. .,Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | - Edwin S Wong
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA
| | - Ann-Marie Rosland
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, PA, USA.,Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Karin Nelson
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.,Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Ashok Reddy
- Health Services Research & Development, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, USA.,Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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9
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Spees LP, Wheeler SB, Zhou X, Amin KB, Baggett CD, Lund JL, Urick BY, Farley JF, Reeder-Hayes KE, Trogdon JG. Changes in chronic medication adherence, costs, and health care use after a cancer diagnosis among low-income patients and the role of patient-centered medical homes. Cancer 2020; 126:4770-4779. [PMID: 32780539 DOI: 10.1002/cncr.33147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/09/2020] [Accepted: 07/18/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Approximately 40% of patients with cancer also have another chronic medical condition. Patient-centered medical homes (PCMHs) have improved outcomes among patients with multiple chronic comorbidities. The authors first evaluated the impact of a cancer diagnosis on chronic medication adherence among patients with Medicaid coverage and, second, whether PCMHs influenced outcomes among patients with cancer. METHODS Using linked 2004 to 2010 North Carolina cancer registry and claims data, the authors included Medicaid enrollees who were diagnosed with breast, colorectal, or lung cancer who had hyperlipidemia, hypertension, and/or diabetes mellitus. Using difference-in-difference methods, the authors examined adherence to chronic disease medications as measured by the change in the percentage of days covered over time among patients with and without cancer. The authors then further evaluated whether PCMH enrollment modified the observed differences between those patients with and without cancer using a differences-in-differences-in-differences approach. The authors examined changes in health care expenditures and use as secondary outcomes. RESULTS Patients newly diagnosed with cancer who had hyperlipidemia experienced a 7-percentage point to 11-percentage point decrease in the percentage of days covered compared with patients without cancer. Patients with cancer also experienced significant increases in medical expenditures and hospitalizations compared with noncancer controls. Changes in medication adherence over time between patients with and without cancer were not determined to be statistically significantly different by PCMH status. Some PCMH patients with cancer experienced smaller increases in expenditures (diabetes) and emergency department use (hyperlipidemia) but larger increases in their inpatient hospitalization rates (hypertension) compared with non-PCMH patients with cancer relative to patients without cancer. CONCLUSIONS PCMHs were not found to be associated with improvements in chronic disease medication adherence, but were associated with lower costs and emergency department visits among some low-income patients with cancer.
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Affiliation(s)
- Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Xi Zhou
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Krutika B Amin
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Christopher D Baggett
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer L Lund
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Benjamin Y Urick
- Division of Practice Advancement and Clinical Education, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joel F Farley
- Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Division of Hematology/Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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10
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Abstract
BACKGROUND Medication adherence is associated with lower health care utilization and savings in specific patient populations; however, few empirical estimates exist at the population level. OBJECTIVE The main objective of this study was to apply a data-driven approach to obtain population-level estimates of the impact of medication nonadherence among Medicare beneficiaries with chronic conditions. RESEARCH DESIGN Medicare fee-for-service (FFS) claims data were used to calculate the prevalence of medication nonadherence among individuals with diabetes, heart failure, hypertension, and hyperlipidemia. Per person estimates of avoidable health care utilization and spending associated with medication adherence, adjusted for healthy adherer effects, from prior literature were applied to the number of nonadherent Medicare beneficiaries. SUBJECTS A 20% random sample of community-dwelling, continuously enrolled Medicare FFS beneficiaries aged 65 years or older with Part D (N=14,657,735) in 2013. MEASURES Avoidable health care costs and hospital use from medication nonadherence. RESULTS Medication nonadherence for diabetes, heart failure, hyperlipidemia, and hypertension resulted in billions of Medicare FFS expenditures, millions in hospital days, and thousands of emergency department visits that could have been avoided. If the 25% of beneficiaries with hypertension who were nonadherent became adherent, Medicare could save $13.7 billion annually, with over 100,000 emergency department visits and 7 million inpatient hospital days that could be averted. CONCLUSION Medication nonadherence places a large resource burden on the Medicare FFS program. Study results provide actionable information for policymakers considering programs to manage chronic conditions. Caution should be used in summing estimates across disease groups, assuming all nonadherent beneficiaries could become adherent, and applying estimates beyond the Medicare FFS population.
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11
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Alfian SD, Pradipta IS, Hak E, Denig P. A systematic review finds inconsistency in the measures used to estimate adherence and persistence to multiple cardiometabolic medications. J Clin Epidemiol 2019; 108:44-53. [DOI: 10.1016/j.jclinepi.2018.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 11/15/2018] [Accepted: 12/05/2018] [Indexed: 02/08/2023]
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Murphy KA, Daumit GL, Stone E, McGinty EE. Physical health outcomes and implementation of behavioural health homes: a comprehensive review. Int Rev Psychiatry 2018; 30:224-241. [PMID: 30822169 PMCID: PMC6499693 DOI: 10.1080/09540261.2018.1555153] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
People with serious mental illness (SMI) have mortality rates 2-3-times higher than the general population, mostly driven by physical health conditions. Behavioural health homes (BHHs) integrate primary care into specialty mental healthcare settings with the goal of improving management of physical health conditions among people with SMI. Implementation and evaluation of BHH models is increasing in the US. This comprehensive review summarized the available evidence on the effects of BHHs on physical healthcare delivery and outcomes and identified perceived barriers and facilitators that have arisen during implementation to-date. This review found 11 studies reporting outcomes data on utilization, screening/monitoring, health promotion, patient-reported outcomes, physical health and/or costs of BHHs. The results of the review suggest that BHHs have resulted in improved primary care access and screening and monitoring for cardiovascular-related conditions among consumers with SMI. No significant effect of BHHs was reported for outcomes on diabetes control, weight management, or smoking cessation. Overall, the physical health outcomes data is limited and mixed, and implementation of BHHs is variable.
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Affiliation(s)
- Karly A. Murphy
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, United States
| | - Gail L. Daumit
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, United States,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
| | - Elizabeth Stone
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, United States
| | - Emma E. McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States
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Swietek KE, Domino ME, Beadles C, Ellis AR, Farley JF, Grove LR, Jackson C, DuBard CA. Do Medical Homes Improve Quality of Care for Persons with Multiple Chronic Conditions? Health Serv Res 2018; 53:4667-4681. [PMID: 30088272 PMCID: PMC6232445 DOI: 10.1111/1475-6773.13024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To examine the association between medical home enrollment and receipt of recommended care for Medicaid beneficiaries with multiple chronic conditions (MCC). DATA SOURCES/STUDY SETTING Secondary claims data from fiscal years 2008-2010. The sample included nonelderly Medicaid beneficiaries with at least two of eight target conditions (asthma, chronic obstructive pulmonary disease, diabetes, hypertension, hyperlipidemia, seizure disorder, major depressive disorder, and schizophrenia). STUDY DESIGN We used linear probability models with person- and year-level fixed effects to examine the association between patient-centered medical home (PCMH) enrollment and nine disease-specific quality-of-care metrics, controlling for selection bias and time-invariant differences between enrollees. DATA COLLECTION METHODS This study uses a dataset that links Medicaid claims with other administrative data sources. PRINCIPAL FINDINGS Patient-centered medical home enrollment was associated with an increased likelihood of receiving eight recommended mental and physical health services, including A1C testing for persons with diabetes, lipid profiles for persons with diabetes and/or hyperlipidemia, and psychotherapy for persons with major depression and persons with schizophrenia. PCMH enrollment was associated with overuse of short-acting β-agonists among beneficiaries with asthma. CONCLUSIONS The PCMH model can improve quality of care for patients with multiple chronic conditions.
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Affiliation(s)
| | - Marisa Elena Domino
- Department of Health Policy and ManagementThe Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNC
| | - Christopher Beadles
- Health Care Quality and Outcomes ProgramRTI InternationalResearch Triangle ParkNC
| | - Alan R. Ellis
- Department of Social WorkNorth Carolina State UniversityRaleighNC
| | | | - Lexie R. Grove
- Department of Health Policy and ManagementThe Gillings School of Global Public HealthThe University of North Carolina at Chapel HillChapel HillNC
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David G, Saynisch P, Luster S, Smith-McLallen A, Chawla R. The impact of patient-centered medical homes on medication adherence? HEALTH ECONOMICS 2018; 27:1805-1820. [PMID: 30070411 DOI: 10.1002/hec.3804] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 04/04/2018] [Accepted: 06/15/2018] [Indexed: 06/08/2023]
Abstract
Accreditation of providers helps resolve the pervasive information asymmetries in health care markets. However, meeting accreditation standards typically involves flexibility in implementation, leading to heterogeneity in performance. For example, the patient-centered medical home (PCMH) is a leading model for recognizing high-performing primary care practices. Flexibility in PCMH implementation allows for varying degrees of emphasis on processes designed to enhance medication adherence. To assess the impact of the PCMH on adherence, we combine 6Â years of detailed patient claims data with a novel dataset containing detailed practice-level PCMH attributes. We study the effects of the number and configuration of adherence-relevant capabilities, using variation in the timing of PCMH adoption to estimate its impact. While PCMH adoption improved overall medication adherence, when combining claims data with the unique recognition data detailing what PCMH capabilities were adopted, we find that these gains are concentrated among patients in practices that adopted more adherence-relevant capabilities. Despite mixed evidence in the literature concerning costs and utilization, our results indicate that PCMH recognition improves medication adherence.
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Affiliation(s)
- Guy David
- Health Care Management Department, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Philip Saynisch
- PhD Program in Health Policy, Harvard University, Cambridge, Massachusetts
| | | | | | - Ravi Chawla
- Informatics Department, Independence Blue Cross, Philadelphia, Pennsylvania
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15
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McGinty EE, Kennedy-Hendricks A, Linden S, Choksy S, Stone E, Daumit GL. An innovative model to coordinate healthcare and social services for people with serious mental illness: A mixed-methods case study of Maryland's Medicaid health home program. Gen Hosp Psychiatry 2018; 51:54-62. [PMID: 29316451 PMCID: PMC5869105 DOI: 10.1016/j.genhosppsych.2017.12.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We conducted a case study examining implementation of Maryland's Medicaid health home program, a unique model for integration of behavioral, somatic, and social services for people with serious mental illness (SMI) in the psychiatric rehabilitation program setting. METHOD We conducted interviews and surveys with health home leaders (N=72) and front-line staff (N=627) representing 46 of the 48 total health home programs active during the November 2015-December 2016 study period. We measured the structural and service characteristics of the 46 health home programs and leaders' and staff members' perceptions of program implementation. RESULTS Health home program structure varied across sites: for example, 15% of programs had co-located primary care providers and 76% had onsite supported employment providers. Most leaders and staff viewed the health home program as having strong organizational fit with psychiatric rehabilitation programs' organizational structures and missions, but noted implementation challenges around health IT, population health management, and coordination with external providers. CONCLUSION Maryland's psychiatric rehabilitation-based health home is a promising model for integration of behavioral, somatic, and social services for people with SMI but may be strengthened by additional policy and implementation supports, including incentives for external providers to engage in care coordination with health home providers.
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Affiliation(s)
- Emma E McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Room 359, Baltimore, MD 21205, United States.
| | - Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, United States
| | - Sarah Linden
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
| | - Seema Choksy
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
| | - Elizabeth Stone
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
| | - Gail L Daumit
- Division of General Internal Medicine, Johns Hopkins School of Medicine, United States
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Go AS, Fan D, Sung SH, Inveiss AI, Romo-LeTourneau V, Mallya UG, Boklage S, Lo JC. Contemporary rates and correlates of statin use and adherence in nondiabetic adults with cardiovascular risk factors: The KP CHAMP study. Am Heart J 2017; 194:25-38. [PMID: 29223433 DOI: 10.1016/j.ahj.2017.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Statin therapy is highly efficacious in the prevention of fatal and nonfatal atherosclerotic events in persons at increased cardiovascular risk. However, its long-term effectiveness in practice depends on a high level of medication adherence by patients. METHODS We identified nondiabetic adults with cardiovascular risk factors between 2008 and 2010 within a large integrated health care delivery system in Northern California. Through 2013, we examined the use and adherence of newly initiated statin therapy based on data from dispensed prescriptions from outpatient pharmacy databases. RESULTS Among 209,704 eligible adults, 68,085 (32.5%) initiated statin therapy during the follow-up period, with 90.4% receiving low-potency statins. At 12 and 24 months after initiating statins, 84.3% and 80.2%, respectively, were actively receiving statin therapy, but only 42% and 30%, respectively, had no gaps in treatment during those time periods. There was also minimal switching between statins or use of other lipid-lowering therapies for augmentation during follow-up. Age≥50 years, Asian/Pacific Islander race, Hispanic ethnicity, prior myocardial infarction, prior ischemic stroke, hypertension, and baseline low-density lipoprotein cholesterol>100 mg/dL were associated with higher adjusted odds, whereas female gender, black race, current smoking, dementia were associated with lower adjusted odds, of active statin treatment at 12 months after initiation. CONCLUSIONS There remain opportunities for improving prevention in patients at risk for cardiovascular events. Our study identified certain patient subgroups that may benefit from interventions to enhance medication adherence, particularly by minimizing treatment gaps and discontinuation of statin therapy within the first year of treatment.
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van den Berk-Clark C, Doucette E, Rottnek F, Manard W, Prada MA, Hughes R, Lawrence T, Schneider FD. Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes, and Experiences of Low-Income Patients? A Systematic Review and Meta-Analysis. Health Serv Res 2017; 53:1777-1798. [PMID: 28670708 DOI: 10.1111/1475-6773.12737] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To examine: (1) what elements of patient-centered medical homes (PCMHs) are typically provided to low-income populations, (2) whether PCMHs improve health behaviors, experiences, and outcomes for low-income groups. DATA SOURCES/STUDY SETTING Existing literature on PCMH utilization among health care organizations serving low-income populations. STUDY DESIGN Systematic review and meta-analysis. DATA COLLECTION/EXTRACTION METHODS We obtained papers through existing systematic and literature reviews and via PubMed, Web of Science, and the TRIP databases, which examined PCMHs serving low-income populations. A total of 434 studies were reviewed. Thirty-three articles met eligibility criteria. PRINCIPAL FINDINGS Patient-centered medical home interventions usually were composed of five of the six recommended components. Overall positive effect of PCMH interventions was d = 0.247 (range -0.965 to 1.42). PCMH patients had better clinical outcomes (d = 0.395), higher adherence (0.392), and lower utilization of emergency rooms (d = -0.248), but there were apparent limitations in study quality. CONCLUSIONS Evidence shows that the PCMH model can increase health outcomes among low-income populations. However, limitations to quality include no assessment for confounding variables. Implications are discussed.
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Affiliation(s)
| | - Emily Doucette
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO.,St. Louis County Department of Health, St. Louis, MO
| | - Fred Rottnek
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - William Manard
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - Mayra Aragon Prada
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - Rachel Hughes
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - Tyler Lawrence
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
| | - F David Schneider
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO
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18
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Shepherd-Banigan M, Domino ME, Wells R, Rutledge R, Hillemeier MM, Van Houtven CH. Do Maternity Care Coordination Services Encourage Use of Behavioral Health Treatment among Pregnant Women on Medicaid? Womens Health Issues 2017; 27:449-455. [PMID: 28427755 PMCID: PMC7497466 DOI: 10.1016/j.whi.2017.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 02/16/2017] [Accepted: 02/24/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Maternity care coordination (MCC) may provide an opportunity to enhance access to behavioral health treatment services. However, this relationship has not been examined extensively in the empirical literature. This study examines the effect of MCC on use of behavioral health services among perinatal women. METHODS Medicaid claims data from October 2008 to September 2010 were analyzed using linear fixed effects models to investigate the effects of receipt of MCC services on mental health and substance use-related service use among Medicaid-eligible pregnant and postpartum women in North Carolina (n = 7,406). RESULTS Receipt of MCC is associated with a 20% relative increase in the contemporaneous use of any mental health treatment (within-person change in probability of any mental health visit 0.5% [95% CI, 0.1%-1.0%], or an increase from 8.3% to 8.8%); MCC in the prior month is associated with a 34% relative increase in the number of mental health visits among women who receive MCC (within-person change in the number of visits received 1.7% [95 CI, 0.2%-3.3%], or from 0.44 to 0.46 mental health visits). No relationship was observed between MCC and Medicaid-funded substance use-related treatment services. CONCLUSIONS MCC may be an effective way to quickly address perinatal mental health needs and engage low-income women in mental health care. However, currently there may be a lost opportunity within MCC to increase access to substance use-related treatment. Future studies should examine how MCC improves access to mental health care such that the program's ability can be strengthened to identify women with substance use-related disorders and transition them into available care.
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Affiliation(s)
- Megan Shepherd-Banigan
- Health Services Research and Development Service, Durham VA Medical Center, Durham, North Carolina.
| | - Marisa E Domino
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Regina Rutledge
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marianne M Hillemeier
- Department of Health Policy and Administration, The Pennsylvania State University, University Park, Pennsylvania
| | - Courtney H Van Houtven
- Health Services Research and Development Service, Durham VA Medical Center, Durham, North Carolina; Department of General Internal Medicine, Duke University Medical Center, Durham, North Carolina
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Fautrel B, Balsa A, Van Riel P, Casillas M, Capron JP, Cueille C, de la Torre I. Influence of route of administration/drug formulation and other factors on adherence to treatment in rheumatoid arthritis (pain related) and dyslipidemia (non-pain related). Curr Med Res Opin 2017; 33:1231-1246. [PMID: 28358217 DOI: 10.1080/03007995.2017.1313209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES A comprehensive review was performed to investigate the effect of route of administration on medication adherence and persistence in rheumatoid arthritis (RA) and to compare adherence/persistence with oral medications between RA and a non-painful disease (dyslipidemia). RESEARCH DESIGN AND METHODS Comprehensive database searches were performed to identify studies investigating medication adherence and/or persistence in adults with RA receiving conventional synthetic or biologic agents. Similar searches were performed for studies of patients with dyslipidemia receiving statins. Studies had to be published after 1998 in English and involve ≥6 months' follow up. MAIN OUTCOME MEASURES Adherence and persistence were compared between the different routes of drug administration in RA, and between the two diseases for oral medications. RESULTS A total of 35 and 28 papers underwent data extraction for RA and dyslipidemia, respectively. Within the constraints of the analysis, adherence and persistence rates appeared broadly similar for the different routes of drug administration in RA. Adherence to oral medications was also broadly similar across the two diseases, but persistence was lower in dyslipidemia. Poor adherence has clinical consequences in both diseases: greater disease activity and risk of flare in RA, and increased serum cholesterol levels and risk of heart and cerebrovascular disease in dyslipidemia. Over 1-3 years, poor adherence to biologic RA medications led to increased resource use and medical costs but lower total direct costs due to reduced biologic drug costs. Conversely, poor adherence to dyslipidemia medications resulted in increased total direct costs. In both diseases, adherence improved with patient education/support. CONCLUSIONS The route of drug administration and the symptomatic (pain) nature of the disease do not appear to be dominant factors for drug adherence or persistence in RA. LIMITATION The wide range of adherence and persistence values and definitions across studies made comparisons between drug formulations and diseases difficult.
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Affiliation(s)
- Bruno Fautrel
- a Pierre et Marie Curie University, Sorbonne Universités ; and Rheumatology Department, Pitié Salpêtrière Hospital , Paris , France
| | - Alejandro Balsa
- b Rheumatology Department and Health Research Institute (Idipaz) , Hospital Universitario de La Paz , Madrid , Spain
| | - Piet Van Riel
- c Scientific Institute for Quality of Healthcare, Radboud University Medical Center , Nijmegen , and Department of Rheumatology , Bernhoven, Uden , The Netherlands
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20
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An J. The Impact of Patient-Centered Medical Homes on Quality of Care and Medication Adherence in Patients with Diabetes Mellitus. J Manag Care Spec Pharm 2017; 22:1272-1284. [PMID: 27783547 PMCID: PMC10397843 DOI: 10.18553/jmcp.2016.22.11.1272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Current evidence suggests that patient-centered medical homes (PCMHs) potentially increase overall quality of disease management, including preventive care. However, there are mixed findings regarding quality of diabetes care, and little evidence exists with respect to the effect of PCMHs on medication adherence in patients with diabetes. OBJECTIVE To investigate associations between PCMHs and process measures of diabetes care, as well as adherence to oral hypoglycemic agents (OHAs) in patients with diabetes in a nationally representative U.S. SAMPLE METHODS Using the 2009-2013 longitudinal data files from the Medical Expenditure Panel Survey, adult diabetes patients were identified. Patients whose usual sources of care have all PCMH features at baseline (i.e., enhanced access after hours and online, shared decision making, and enhanced patient engagement) were categorized as the PCMH group, which was compared with patients without PCMH features. Process measures of diabetes care included ≥ 2 hemoglobin A1c tests and ≥ 1 cholesterol test, foot examination, dilated eye examination, and flu vaccination during 1 year of follow-up. Medication possession ratio (MPR) during follow-up was calculated for patients with OHAs without any insulin use, with MPR ≥ 80% considered to be adherent to OHAs. Univariate and multivariate regression models considering sampling strata and weights were used to examine the association between the PCMH and study outcomes. RESULTS A total of 3,334 patients with diabetes was identified, representing 61 million U.S. lives. The mean (SE) age was 61.6 (0.3) years, and 52.4% of patients were female. The mean (SE) years of having diabetes was 12.0 (0.2) years. Approximately 11.4% of the patients were categorized as the PCMH group at baseline, and only 3.6% of those patients remained in the PCMH group for 2 years. Of the diabetic patients identified, only 26.9% met all of the diabetes care process measure criteria defined in this study. A higher proportion of patients met process measure criteria in the PCMH group compared with the non-PCMH group (33.8% vs. 26.0%, respectively, P = 0.015). The weighted mean MPR (95% CI) of OHAs from the 2 groups were not statistically different (0.68, 95% CI = 0.63-0.74 for the PCMH group; 0.77, 95% CI = 0.72-0.82 for the non-PCMH group, P = 0.675), resulting in 47.4% of adherent patients in the study population. Overall, the PCMH group was associated with improvement in the process measures of diabetes care (adjusted odds ratios [OR] = 1.42, 95% CI = 1.06-1.91). The effect was greater among the patients who stayed in the PCMH group for 2 years (OR = 2.09, 95% CI = 1.27-3.45); were aged < 65 years (OR = 2.19, 95% CI = 1.47-3.28); or had less than 3 comorbid conditions (OR = 2.38, 95% CI = 1.46-3.88). However, the PCMH group was not associated with an increased adherence to OHAs (P = 0.495) or an increase in MPR (P = 0.570). CONCLUSIONS Patients with all PCMH features were associated with improvement in the process measures of diabetes care, but not in adherence to OHAs. Future studies should investigate the mechanism of PCMHs in overall quality of care, as well as medication adherence. DISCLOSURES No outside funding supported this study. The author reports no conflicts of interests.
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Affiliation(s)
- JaeJin An
- 1 Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, Pomona, California
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Jones AL, Mor MK, Cashy JP, Gordon AJ, Haas GL, Schaefer JH, Hausmann LRM. Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders. J Gen Intern Med 2016; 31:1435-1443. [PMID: 27325318 PMCID: PMC5130946 DOI: 10.1007/s11606-016-3776-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/12/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown. OBJECTIVE We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs. DESIGN We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients. PARTICPANTS Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]). MAIN MEASURES Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey. RESULTS Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs =  3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support. CONCLUSIONS In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240-1001, USA.
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gretchen L Haas
- VISN4 Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence, Durham, NC, USA
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Slazak EM, Kozakiewicz JT, Winters NS, Smith JR, Monte SV. Statin Adherence Rates in Patients Utilizing a Patient-Centered Medical Home-Based Pharmacy. J Pharm Pract 2016; 30:516-520. [PMID: 27599748 DOI: 10.1177/0897190016665550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medication nonadherence contributes to approximately US$290 billion per year in avoidable health-care spending. Statins are of particular interest because of their importance to patient outcomes, costs of treatment failure, and categorization as a Medicare star measure linked to financial reimbursement. OBJECTIVE To evaluate statin adherence as defined by the proportion of days covered (PDC) among patients who use an embedded dispensing pharmacy in a patient-centered medical home (PCMH). METHODS This study is a retrospective chart review of Lifetime Health Medical Group's electronic health record and third-party prescription claims data of statin therapy. Statin adherence is reported using PDC, with 0.8 or greater considered adherent for statin therapy. Statistics used include 2-sample unpaired t test to compare PDC between gender and age, and analysis of variance was used to determine differences in PDC among different insurance types. RESULTS One hundred ninety-three patients were included, and 917 statin prescriptions were filled. PDC for statin medications in the population was 0.92 ± 0.20. Eighty-six percent of patients were considered adherent, with a PDC ≥80%. The average insurance and patient costs for brand prescriptions (n = 106) were US$233 ± US$143 and US$31 ± US$27, respectively, and costs for generic prescriptions (n = 811) were US$8 ± US$13 and US$7 ± US$6, respectively. CONCLUSION Statin adherence rates for patients utilizing a dispensing pharmacy embedded in a large PCMH exceed the national average of 40% to 50% adherence.
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Affiliation(s)
- Erin M Slazak
- 1 State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Buffalo, NY, USA
| | - Jessica T Kozakiewicz
- 1 State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Buffalo, NY, USA.,2 Lifetime Health Medical Group, Buffalo, NY, USA.,3 University of Rochester Medical Center, Rochester, NY, USA
| | - Natalie S Winters
- 1 State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Buffalo, NY, USA
| | - Jason R Smith
- 2 Lifetime Health Medical Group, Buffalo, NY, USA.,3 University of Rochester Medical Center, Rochester, NY, USA
| | - Scott V Monte
- 1 State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences, Department of Pharmacy Practice, Buffalo, NY, USA
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Bowdoin JJ, Rodriguez-Monguio R, Puleo E, Keller D, Roche J. Associations between the patient-centered medical home and preventive care and healthcare quality for non-elderly adults with mental illness: A surveillance study analysis. BMC Health Serv Res 2016; 16:434. [PMID: 27557785 PMCID: PMC4997759 DOI: 10.1186/s12913-016-1676-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 08/16/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patient-centered medical homes (PCMHs) may improve outcomes for non-elderly adults with mental illness, but the extent to which PCMHs are associated with preventive care and healthcare quality for this population is largely unknown. Our study addresses this gap by assessing the associations between receipt of care consistent with the PCMH and preventive care and healthcare quality for non-elderly adults with mental illness. METHODS This surveillance study used self-reported data for 6,908 non-elderly adults with mental illness participating in the 2007-2012 Medical Expenditure Panel Survey. Preventive care and healthcare quality measures included: participant rating of all healthcare; cervical, breast, and colorectal cancer screening; current smoking; smoking cessation advice; flu shot; foot exam and eye exam for people with diabetes; and follow-up after emergency room visit for mental illness. Multiple logistic regression models were developed to compare the odds of meeting preventive care and healthcare quality measures for participants without a usual source of care, participants with a non-PCMH usual source of care, and participants who received care consistent with the PCMH. RESULTS Compared to participants without a usual source of care, those with a non-PCMH usual source of care had better odds of meeting almost all measures examined, while those who received care consistent with the PCMH had better odds of meeting most measures. Participants who received care consistent with the PCMH had better odds of meeting only one measure compared to participants with a non-PCMH usual source of care. CONCLUSIONS Compared with having a non-PCMH usual source of care, receipt of care consistent with the PCMH does not appear to be associated with most preventive care or healthcare quality measures. These findings raise concerns about the potential value of the PCMH for non-elderly adults with mental illness and suggest that alternative models of primary care are needed to improve outcomes and address disparities for this population.
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Affiliation(s)
- Jennifer J Bowdoin
- Health Policy and Management, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 North Pleasant Street, Amherst, MA, 01003, USA.
| | - Rosa Rodriguez-Monguio
- Health Policy and Management, School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 North Pleasant Street, Amherst, MA, 01003, USA
| | - Elaine Puleo
- School of Public Health and Health Sciences, University of Massachusetts Amherst, 715 North Pleasant Street, Amherst, MA, 01003, USA
| | - David Keller
- Department of Pediatrics, University of Colorado School of Medicine, 13123 E. 16th Avenue, B065, Aurora, CO, 80045, USA
| | - Joan Roche
- The Roche Associates, 37 Westmoreland Avenue, Longmeadow, MA, 01106, USA
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Dunlay SM, Chamberlain AM. Multimorbidity in Older Patients with Cardiovascular Disease. CURRENT CARDIOVASCULAR RISK REPORTS 2016; 10. [PMID: 27274775 DOI: 10.1007/s12170-016-0491-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Multimorbidity affects more than two thirds of older individuals and the vast majority of patients with chronic cardiovascular disease. Patients with multimorbidity have high resource utilization, poor mobility, and poor health status and are at an increased risk for death. The presence of multimorbidity imposes numerous management challenges in caring for patients with chronic cardiovascular disease. It complicates decision-making, promotes fragmented care, and imposes an immense burden on the patient and their social support system. Novel models of care, such as the cardiovascular patient-centered medical home, are needed to provide high-quality, efficient, effective care to this growing population.
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Affiliation(s)
- Shannon M Dunlay
- Division of Cardiovascular Diseases, Department of Medicine, 200 First Street SW, Rochester, MN 55905, USA; Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Alanna M Chamberlain
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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