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Tierney AA, Brown TT, Aguilera A, Shortell SM, Rodriguez HP. Conjoint Analysis of Telemedicine Preferences for Hypertension Management Among Adult Patients. Telemed J E Health 2024; 30:692-704. [PMID: 37843962 PMCID: PMC10924055 DOI: 10.1089/tmj.2023.0254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 10/18/2023] Open
Abstract
Background: Telemedicine has been differentially utilized by different demographic groups during COVID-19, exacerbating inequities in health care. We conducted conjoint and latent class analyses to understand factors that shape patient preferences for hypertension management telemedicine appointments. Methods: We surveyed 320 adults, oversampling participants from households that earned <$50K per year (77.2%) and speak a language other than English at home (68.8%). We asked them to choose among 2 hypothetical appointments through 12 conjoint tasks measuring 6 attributes. Individual utilities for attributes were constructed using logit estimation, and latent classes were identified and compared by demographic and clinical characteristics. Results: Respondents preferred in-person visits (0.353, standard error [SE] = 0.039) and video appointments conducted through a secure patient portal (0.002, SE = 0.040). Respondents also preferred seeing a clinician with whom they have an established relationship (0.168, SE = 0.021). We found four latent classes: "in-person" (26.5% of participants) who strongly weighted in-person appointments, "cost conscious" (8.1%) who prioritized the lowest copay ($0 to $10), "expedited" (19.7%) who prioritized getting the earliest appointment possible (same/next day or at least within the next week), and "comprehensive" (45.6%) who had preferences for in-person care and telemedicine appointments through a secure portal, low copayments, and the ability to see a familiar clinician. Conclusions: Appointment preferences for hypertension management can be segmented into four groups that prioritize (1) in-person care, (2) low copayments, (3) expedited care, and (4) balanced preferences for in-person and telemedicine appointments. Evidence is needed to clarify whether aligning appointment offerings with patients' preferences can improve care quality, equity, and efficiency.
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Affiliation(s)
- Aaron A. Tierney
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Timothy T. Brown
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Adrian Aguilera
- School of Social Welfare, University of California, Berkeley, Berkeley, California, USA
| | - Stephen M. Shortell
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
| | - Hector P. Rodriguez
- School of Public Health, University of California, Berkeley, Berkeley, California, USA
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Lee J, Hung DY, Reponen E, Rundall TG, Tierney AA, Fournier PL, Shortell SM. Associations Between Lean IT Management and Financial Performance in US Hospitals. Qual Manag Health Care 2023:00019514-990000000-00063. [PMID: 37817320 DOI: 10.1097/qmh.0000000000000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
BACKGROUND AND OBJECTIVES To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes. METHODS Primary data were sourced from 1222 hospitals that responded to the National Survey of Lean (NSL)/Transformational Performance Improvement, which was fielded to 4500 general medical-surgical hospitals across the United States. Secondary sources included hospital performance data from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). We performed 2 sets of multivariable regressions using data gathered from US hospitals, linked to AHRQ and CMS performance outcomes. We examined 10 different outcomes measuring financial performance, quality of care, and patient experience, and their associations with Lean adoption within hospital IT departments. We then focused only on those hospitals that adopted Lean in IT to identify specific practices associated with performance. RESULTS Controlling for other factors, adoption of Lean IT management was associated with lower length of stay (b = -0.098, P = .018) and inpatient expense per discharge (b = -0.112, P = .090). Specifically, use of visual management tools (eg, A3 storyboards, status sheets) was associated with lower adjusted inpatient expense per discharge (b = -0.176, P = .034) and higher earnings before interest, taxes, depreciation, and amortization margin (b = 0.124, P = .042). Such tools were also associated with hospital participation in bundled payment programs (odds ratio = 2.326; P = .046; 95% confidence interval, 0.979-5.527) and percentage of net revenue paid on a shared risk basis (b = 0.188, P = .031). CONCLUSIONS Lean IT management was associated with positive financial performance, particularly with hospital participation in value-based payment. More detailed study is needed to understand other influential factors and types of work processes, activities, or mechanisms by which high-functioning IT can contribute to financial outcomes.
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Affiliation(s)
- Justin Lee
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley (Mr Lee); Division of Biological Sciences, College of Letters and Sciences, University of California, Berkeley (Mr Lee); Department of Anesthesiology and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland (Dr Reponen); and Department of Information Systems and Quantitative Methods, Business School, Université de Sherbrooke, Sherbrooke, Canada (Dr Fournier)
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Roey T, Hung DY, Rundall TG, Fournier PL, Zhong A, Shortell SM. Lean Performance Indicators and Facilitators of Outcomes in U.S. Public Hospitals. J Healthc Manag 2023; 68:325-341. [PMID: 37678825 DOI: 10.1097/jhm-d-22-00107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
GOAL This study investigated the association between Lean and performance outcomes in U.S. public hospitals. Public hospitals face substantial pressure to deliver high-quality care with limited resources. Lean-based management systems can provide these hospitals with alternative approaches to improve efficiency and effectiveness. Prior research shows that Lean can have positive impacts in hospitals ranging in ownership type, but more study is needed, specifically in publicly owned hospitals. METHODS We performed multivariable regressions using data from the 2017 National Survey of Lean/Transformational Performance Improvement. The data were linked to publicly available hospital performance data from the Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services. We examined 11 outcomes measuring financial performance, quality of care, and patient experience and their associations with Lean adoption. We also explored potential drivers of positive outcomes by examining Lean implementation in each hospital, measured as the number of units using Lean tools and practices; leader commitment to Lean principles; Lean training and education among physicians, nurses, and managers; and use of a daily management system among C-suite leaders and managers. PRINCIPAL FINDINGS Lean adoption and implementation were associated with improved performance in U.S. public hospitals. Compared with hospitals that did not adopt Lean, those that did had significantly lower adjusted inpatient expenses per discharge and higher-than-average national scores on the appropriate use of medical imaging and timeliness of care. The study results also showed marginally significant improvements in patient experience and hospital earnings before interest, taxes, depreciation, and amortization margins. Focusing on these select outcomes, we found that drivers of such improvements involved the extent of Lean implementation, as reflected by leadership commitment, daily management, and training/education while controlling for the number of years using Lean. PRACTICAL APPLICATIONS Lean is a method of continuous improvement centered around a culture of providing high-value care for patients. Our findings provide insight into the potential benefits of Lean in U.S. public hospitals. Notably, they suggest that leader buy-in is key to success. When executives and managers support Lean initiatives and provide proper training for the workforce, improved financial and operational performance can result. This commitment, starting with upper management, may also play a broader role in the effort to reform healthcare while having a positive impact on patient care in U.S. public hospitals.
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Affiliation(s)
| | | | | | | | | | - Stephen M Shortell
- Center for Lean Engagement & Research, Division of Health Policy and Management, University of California, Berkeley, California
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Hague EL, Brown TT, Brewster A, Shortell SM, Rodriguez HP. Hospital Characteristics Associated With Clinically Integrated Network Participation. Med Care 2023; 61:521-527. [PMID: 37314353 DOI: 10.1097/mlr.0000000000001877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Increased integration of physician organizations and hospitals into health systems has not necessarily improved clinical integration or patient outcomes. However, federal regulators have issued favorable opinions for clinically integrated networks (CINs) as a way to pursue coordination between hospitals and physicians. Hospital organizational affiliations, including independent practice associations (IPA), physician-hospital organizations (PHOs), and accountable care organizations (ACOs), may support CIN participation. No empirical evidence, however, exists about factors associated with CIN participation. METHODS Data from the 2019 American Hospital Association survey (n = 4405) were analyzed to quantify hospital CIN participation. Multivariable logistic regression models were estimated to examine whether IPA, PHO, and ACO affiliations were associated with CIN participation, controlling for market factors and hospital characteristics. RESULTS In 2019, 34.6% of hospitals participated in a CIN. Larger, not-for-profit, and metropolitan hospitals were more likely to participate in CINs. In adjusted analyses, hospitals participating in CINs were more likely to have an IPA (9.5% points, P < 0.001), a PHO (6.1% points, P < 0.001), and ACO (19.3% points, P < 0.001) compared with hospitals not participating in a CIN. CONCLUSIONS Over one-third of hospitals participate in a CIN, despite limited evidence about their effectiveness in delivering value. Results suggest that CIN participation may be a response to integrative norms. Future work should attempt to better define CIN participation and strive to disentangle overlapping organizational participation.
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Affiliation(s)
- Emily L Hague
- University of California, Berkeley, School of Public Health, Berkeley, CA
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Miller-Rosales C, Brewster AL, Shortell SM, Rodriguez HP. Multilevel influences on patient engagement and chronic care management. Am J Manag Care 2023; 29:196-202. [PMID: 37104834 DOI: 10.37765/ajmc.2023.89348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
OBJECTIVES Physician practices are increasingly owned by health systems, which may support or hinder adoption of innovative care processes for adults with chronic conditions. We examined health system- and physician practice-level capabilities associated with adoption of (1) patient engagement strategies and (2) chronic care management processes for adult patients with diabetes and/or cardiovascular disease. STUDY DESIGN We analyzed data collected from the National Survey of Healthcare Organizations and Systems, a nationally representative survey of physician practices (n = 796) and health systems (n = 247) (2017-2018). METHODS Multivariable multilevel linear regression models estimated system- and practice-level characteristics associated with practice adoption of patient engagement strategies and chronic care management processes. RESULTS Health systems with processes to assess clinical evidence (β = 6.54 points on a 0-100 scale; P = .004) and with more advanced health information technology (HIT) functionality (β = 2.77 points per SD increase on a 0-100 scale; P = .03) adopted more practice-level chronic care management processes, but not patient engagement strategies, compared with systems lacking these capabilities. Physician practices with cultures oriented to innovation, more advanced HIT functionality, and with a process to assess clinical evidence adopted more patient engagement strategies and chronic care management processes. CONCLUSIONS Health systems may be better able to support the adoption of practice-level chronic care management processes, which have a strong evidence base for implementation, compared with patient engagement strategies, which have less evidence to guide effective implementation. Health systems have an opportunity to advance patient-centered care by expanding practice-level HIT functionality and developing processes to appraise clinical evidence for practices.
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Affiliation(s)
| | | | | | - Hector P Rodriguez
- University of California, Berkeley, 2121 Berkeley Way, Berkeley, CA 94720-7360.
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Brown TT, Hague E, Neumann A, Rodriguez HP, Shortell SM. Impact of a selective narrow network with comprehensive patient navigation on access, utilization, expenditures, and enrollee experiences. Health Serv Res 2023; 58:332-342. [PMID: 36111577 PMCID: PMC10012245 DOI: 10.1111/1475-6773.14066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the effect of enrollee switching from a broad-network accountable care organization (ACO) health maintenance organization (HMO) to a "high performance" ACO-HMO with a selective narrow network and comprehensive patient navigation system on access, utilization, expenditures, and enrollee experiences. DATA SOURCES Secondary administrative data were obtained for 2016-2020, and primary interview and survey data in 2021. STUDY DESIGN Fixed-effects instrumental variable analyses of administrative data and regression analyses of survey data. Outcomes included access, utilization, expenditures, and enrollee experience. Background information was gathered via interviews. DATA COLLECTION/EXTRACTION METHODS We obtained medical expenditure/enrollment and access data on continuously enrolled members in a broad-network ACO-HMO (n = 24,555), a subset of those who switched to a high-performance ACO-HMO in 2018 (n = 7664); interviews of organizational leaders (n = 13); and an enrollee survey (n = 512). PRINCIPAL FINDINGS Health care effectiveness data and information Set (HEDIS) access measures were not different across plans. However, annual utilization dropped by 15.5 percentage points (95% CI: 18.1, 12.9) more in the high-performance ACO-HMO, with relative annual expenditures declining by $1251 (95% CI: $1461, $1042) per person per year. High-performance ACO-HMO enrollees were 10.1 percentage points (95% CI 0.001, 0.201) more likely to access primary care usually or always as soon as needed and 11.2 percentage points (95% CI 0.007, 0.217) more likely to access specialty care usually or always as soon as needed. Plan satisfaction was 7.1 percentage points (95% CI: -0.001, 0.138) higher in the high-performance ACO-HMO. Interviewees noted the comprehensive patient navigation system was designed to ensure patients remained in the narrow network to receive care. CONCLUSIONS ACO and HMO contracts with selective narrow networks supported by comprehensive patient navigation can reduce expenditures and improve specialty access and patient satisfaction compared to broad-network plans that lack these features. Payers should consider implementing narrow networks with comprehensive support systems.
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Affiliation(s)
- Timothy T. Brown
- School of Public HealthUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Emily Hague
- School of Public HealthUniversity of CaliforniaBerkeleyCaliforniaUSA
| | - Alicia Neumann
- Division of Geriatrics, Department of MedicineUniversity of CaliforniaSan FranciscoCaliforniaUSA
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Tierney AA, Payán DD, Brown TT, Aguilera A, Shortell SM, Rodriguez HP. Telehealth Use, Care Continuity, and Quality: Diabetes and Hypertension Care in Community Health Centers Before and During the COVID-19 Pandemic. Med Care 2023; 61:S62-S69. [PMID: 36893420 PMCID: PMC9994572 DOI: 10.1097/mlr.0000000000001811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND Community health centers (CHCs) pivoted to using telehealth to deliver chronic care during the coronavirus COVID-19 pandemic. While care continuity can improve care quality and patients' experiences, it is unclear whether telehealth supported this relationship. OBJECTIVE We examine the association of care continuity with diabetes and hypertension care quality in CHCs before and during COVID-19 and the mediating effect of telehealth. RESEARCH DESIGN This was a cohort study. PARTICIPANTS Electronic health record data from 166 CHCs with n=20,792 patients with diabetes and/or hypertension with ≥2 encounters/year during 2019 and 2020. METHODS Multivariable logistic regression models estimated the association of care continuity (Modified Modified Continuity Index; MMCI) with telehealth use and care processes. Generalized linear regression models estimated the association of MMCI and intermediate outcomes. Formal mediation analyses assessed whether telehealth mediated the association of MMCI with A1c testing during 2020. RESULTS MMCI [2019: odds ratio (OR)=1.98, marginal effect=0.69, z=165.50, P<0.001; 2020: OR=1.50, marginal effect=0.63, z=147.73, P<0.001] and telehealth use (2019: OR=1.50, marginal effect=0.85, z=122.87, P<0.001; 2020: OR=10.00, marginal effect=0.90, z=155.57, P<0.001) were associated with higher odds of A1c testing. MMCI was associated with lower systolic (β=-2.90, P<0.001) and diastolic blood pressure (β=-1.44, P<0.001) in 2020, and lower A1c values (2019: β=-0.57, P=0.007; 2020: β=-0.45, P=0.008) in both years. In 2020, telehealth use mediated 38.7% of the relationship between MMCI and A1c testing. CONCLUSIONS Higher care continuity is associated with telehealth use and A1c testing, and lower A1c and blood pressure. Telehealth use mediates the association of care continuity and A1c testing. Care continuity may facilitate telehealth use and resilient performance on process measures.
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Affiliation(s)
- Aaron A. Tierney
- Department of Health Policy and Management, University of California, Berkeley
| | - Denise D. Payán
- Department of Health, Society, and Behavior, University of California, Irvine
| | - Timothy T. Brown
- Department of Health Policy and Management, University of California, Berkeley
| | - Adrian Aguilera
- Department of Health Policy and Management, University of California, Berkeley
| | - Stephen M. Shortell
- Department of Health Policy and Management, University of California, Berkeley
| | - Hector P. Rodriguez
- Department of Health Policy and Management, University of California, Berkeley
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Rodriguez HP, Ciemins E, Rubio K, Rattelman C, Cuddeback JK, Mohl JT, Bibi S, Shortell SM. Health systems and telemedicine adoption for diabetes and hypertension care. Am J Manag Care 2023; 29:42-49. [PMID: 36716153 PMCID: PMC9897448 DOI: 10.37765/ajmc.2023.89302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The COVID-19 pandemic accelerated telemedicine use nationally, but differences across health systems are understudied. We examine telemedicine use for adults with diabetes and/or hypertension across 10 health systems and analyze practice and patient characteristics associated with greater use. STUDY DESIGN Encounter-level data from the AMGA Optum Data Warehouse for March 13, 2020, to December 31, 2020, were analyzed, which included 3,016,761 clinical encounters from 764,521 adults with diabetes and/or hypertension attributed to 1 of 1207 practice sites with at least 50 system-attributed patients. METHODS Linear spline regression estimated whether practice size and ownership were associated with telemedicine during the adoption (weeks 0-4), de-adoption (weeks 5-12), and maintenance (weeks 13-42) periods, controlling for patient socioeconomic and clinical characteristics. RESULTS Telemedicine use peaked at 11% to 42% of weekly encounters after 4 weeks. In adjusted analyses, small practices had lower telemedicine use for adults with diabetes during the maintenance period compared with larger practices. Practice ownership was not associated with telemedicine use. Practices with higher proportions of Black patients continued to expand telemedicine use during the de-adoption and maintenance periods. CONCLUSIONS Practice ownership was not associated with telemedicine use during first months of the pandemic. Small practices de-adopted telemedicine to a greater degree than medium and large practices. Technical support for small practices, irrespective of their ownership, could enable telemedicine use for adults with diabetes and/or hypertension.
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Affiliation(s)
- Hector P. Rodriguez
- University of California, Berkeley, School of Public Health, Berkeley, CA, 2121 Berkeley Way, Berkeley, CA 94720-7360
| | | | - Karl Rubio
- University of California, Berkeley, School of Public Health, Berkeley, CA, 2121 Berkeley Way, Berkeley, CA 94720-7360
| | | | | | - Jeff T. Mohl
- AMGA, One Prince Street, Alexandria, VA 22314-3318
| | - Salma Bibi
- University of California, Berkeley, School of Public Health, Berkeley, CA, 2121 Berkeley Way, Berkeley, CA 94720-7360
| | - Stephen M. Shortell
- University of California, Berkeley, School of Public Health, Berkeley, CA, 2121 Berkeley Way, Berkeley, CA 94720-7360
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Hung DY, Rundall TG, Lee J, Khandel N, Shortell SM. Managing Through a Pandemic: A Daily Management System for COVID-19 Response and Recovery. J Healthc Manag 2022; 67:446-457. [PMID: 36350582 PMCID: PMC9640242 DOI: 10.1097/jhm-d-21-00319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
GOAL This study explored the use of a Lean daily management system (DMS) for COVID-19 response and recovery in U.S. hospitals and health systems. Originally developed in manufacturing, Lean is an evidence-based approach to quality and process improvement in healthcare. Although Lean has been studied in individual hospital units and outpatient practices, it has not been examined as a whole system response to crisis events. METHODS We conducted qualitative interviews with 46 executive leaders, clinical leaders, and frontline staff in four hospitals and health systems across the United States. We developed a semistructured interview guide to understand DMS implementation in these care delivery organizations. As interviews took place 6-8 months following the onset of the pandemic, a subset of our interview questions centered on DMS use to meet the demands of COVID-19. Based on a deductive approach to qualitative analysis, we identified clusters of themes that described how DMS facilitated rapid system response to the public health emergency. PRINCIPAL FINDINGS There were many important ways in which U.S. hospitals and health systems leveraged their DMS to address COVID-19 challenges. These included the use of tiered huddles to facilitate rapid communication, the creation of standard work for redeployed staff, and structured problem-solving to prioritize new areas for improvement. We also discovered ways that the pandemic itself affected DMS implementation in all organizations. COVID-19 universally created greater DMS visibility by opening lines of communication among leadership, strengthening measurement and accountability, and empowering staff to develop solutions at the front lines. Many lessons learned using DMS for crisis management will carry forward into COVID-19 recovery efforts. Lessons include expanding telehealth, reactivating incident command systems as needed, and efficiently coordinating resources amid potential future shortages. PRACTICAL APPLICATIONS Overall, the Lean DMS functioned as a robust property that enabled quick organizational response to unpredictable events. Our findings on the use of DMS are consistent with organizational resilience that emphasizes collective sense-making and awareness of incident status, team decision-making, and frequent interaction and coordination. These features of resilience are supported by DMS practices such as tiered huddles for rapid information dissemination and alignment across organizational hierarchies. When used in conjunction with plan-do-study-act methodology, huddles provide teams with enhanced feedback that strengthens their ability to make changes as needed. Moreover, gaps between work-as-imagined (how work should be done) and work-as-done (how work is actually done) may be exacerbated in the initial chaos of emergency events but can be minimized through the development of standard work protocols. As a facilitator of resilience, the Lean DMS may be used in a variety of challenging situations to ensure high standards of care.
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Affiliation(s)
- Dorothy Y. Hung
- School of Public Health, University of California at Berkeley, Berkeley, California
| | | | - Justin Lee
- School of Public Health, University of California at Berkeley
| | - Negeen Khandel
- School of Public Health, University of California at Berkeley
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Rodriguez HP, Kyalwazi MJ, Lewis VA, Rubio K, Shortell SM. Adoption of Patient-Reported Outcomes by Health Systems and Physician Practices in the USA. J Gen Intern Med 2022; 37:3885-3892. [PMID: 35484368 PMCID: PMC9640524 DOI: 10.1007/s11606-022-07631-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low. OBJECTIVE This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption. DESIGN Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression. PARTICIPANTS A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs. MAIN MEASURES Health system and physician practice adoption of PROs for depression, pain, and disability. KEY RESULTS Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs. CONCLUSIONS Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.
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Affiliation(s)
- Hector P Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
| | - Martin J Kyalwazi
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Valerie A Lewis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, Chapel Hill, NC, USA
| | - Karl Rubio
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
| | - Stephen M Shortell
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, CA, USA
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Miller‐Rosales C, Miake‐Lye IM, Brewster AL, Shortell SM, Rodriguez HP. Pathways for primary care practice adoption of patient engagement strategies. Health Serv Res 2022; 57:1087-1093. [PMID: 35188976 PMCID: PMC9441284 DOI: 10.1111/1475-6773.13959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/18/2021] [Accepted: 02/15/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To identify potential orderings of primary care practice adoption of patient engagement strategies overall and separately for interpersonally and technologically oriented strategies. DATA SOURCES We analyzed physician practice survey data (n = 71) on the adoption of 12 patient engagement strategies. STUDY DESIGN Mokken scale analysis was used to assess latent traits among the patient engagement strategies. DATA COLLECTION Three groupings of patient engagement strategies were analyzed: (1) all 12 patient engagement strategies, (2) six interpersonally oriented strategies, and (3) six technologically oriented strategies. PRINCIPAL FINDINGS We did not find scalability among all 12 patient engagement strategies, however, separately analyzing the subgroups of six interpersonally and six technologically oriented strategies demonstrated scalability (Loevinger's H coefficient of scalability [range]: interpersonal strategies, H = 0.54 [0.49-0.60], technological strategies, H = 0.42 [0.31, 0.54]). Ordered patterns emerged in the adoption of strategies for both interpersonal and technological types. CONCLUSIONS Common pathways of practice adoption of patient engagement strategies were identified. Implementing interpersonally intensive patient engagement strategies may require different physician practice capabilities than technological strategies. Rather than simultaneously adopting multiple patient engagement strategies, gradual and purposeful practice adoption may improve the impact of these strategies and support sustainability.
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Affiliation(s)
| | - Isomi M. Miake‐Lye
- Evidence‐based Synthesis Program (ESP) CenterVeterans Affairs Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Department of Health Policy and ManagementFielding School of Public Health, University of California, Los AngelesLos AngelesCaliforniaUSA
| | - Amanda L. Brewster
- School of Public HealthUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Stephen M. Shortell
- School of Public HealthUniversity of California, BerkeleyBerkeleyCaliforniaUSA
| | - Hector P. Rodriguez
- School of Public HealthUniversity of California, BerkeleyBerkeleyCaliforniaUSA
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12
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Miller-Rosales C, Lewis VA, Shortell SM, Rodriguez HP. Adoption of Patient Engagement Strategies by Physician Practices in the United States. Med Care 2022; 60:691-699. [PMID: 35833416 PMCID: PMC9378564 DOI: 10.1097/mlr.0000000000001748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Patient engagement strategies can equip patients with tools to navigate treatment decisions and improve patient-centered outcomes. Despite increased recognition about the importance of patient engagement, little is known about the extent of physician practice adoption of patient engagement strategies nationally. METHODS We analyzed data collected from the National Survey of Healthcare Organizations and Systems (NSHOS) on physician practice adoption of patient engagement strategies. Stratified-cluster sampling was used to select physician practices operating under different organizational structures. Multivariable linear regression models estimated the association of practice ownership, health information technology functionality, use of screening activities, patient responsiveness, chronic care management processes, and the adoption of patient engagement strategies, including shared decision-making, motivational interviewing, and shared medical appointments. All regression models controlled for participation in payment reforms, practice size, Medicaid revenue percentage, and geographic region. RESULTS We found modest and varied adoption of patient engagement strategies by practices of different ownership types, with health system-owned practices having the lowest adoption of ownership types. Practice capabilities, including chronic care management processes, routine screening of medical and social risks, and patient care dissemination strategies were associated with greater practice-level adoption of patient engagement strategies. CONCLUSIONS This national study is the first to characterize the adoption of patient engagement strategies by US physician practices. We found modest adoption of shared decision-making and motivational interviewing, and low adoption of shared medical appointments. Risk-based payment reform has the potential to motivate greater practice-level patient engagement, but the extent to which it occurs may depend on internal practice capabilities.
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Affiliation(s)
| | - Valerie A Lewis
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen M Shortell
- Division of Health Policy and Management, University of California, Berkeley, School of Public Health, Berkeley, CA
| | - Hector P Rodriguez
- Division of Health Policy and Management, University of California, Berkeley, School of Public Health, Berkeley, CA
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Kim JG, Rodriguez HP, Holmboe ES, McDonald KM, Mazotti L, Rittenhouse DR, Shortell SM, Kanter MH. The Reliability of Graduate Medical Education Quality of Care Clinical Performance Measures. J Grad Med Educ 2022; 14:281-288. [PMID: 35754636 PMCID: PMC9200256 DOI: 10.4300/jgme-d-21-00706.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/26/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Graduate medical education (GME) program leaders struggle to incorporate quality measures in the ambulatory care setting, leading to knowledge gaps on how to provide feedback to residents and programs. While nationally collected quality of care data are available, their reliability for individual resident learning and for GME program improvement is understudied. OBJECTIVE To examine the reliability of the Healthcare Effectiveness Data and Information Set (HEDIS) clinical performance measures in family medicine and internal medicine GME programs and to determine whether HEDIS measures can inform residents and their programs with their quality of care. METHODS From 2014 to 2017, we collected HEDIS measures from 566 residents in 8 family medicine and internal medicine programs under one sponsoring institution. Intraclass correlation was performed to establish patient sample sizes required for 0.70 and 0.80 reliability levels at the resident and program levels. Differences between the patient sample sizes required for reliable measurement and the actual patients cared for by residents were calculated. RESULTS The highest reliability levels for residents (0.88) and programs (0.98) were found for the most frequently available HEDIS measure, colorectal cancer screening. At the GME program level, 87.5% of HEDIS measures had sufficient sample sizes for reliable measurement at alpha 0.7 and 75.0% at alpha 0.8. Most resident level measurements were found to be less reliable. CONCLUSIONS GME programs may reliably evaluate HEDIS performance pooled at the program level, but less so at the resident level due to patient volume.
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Affiliation(s)
- Jung G. Kim
- Jung G. Kim, PhD, MPH, is Assistant Professor, Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science
| | - Hector P. Rodriguez
- Hector P. Rodriguez, PhD, MPH, is the Kaiser Permanente Professor of Health Policy and Management, University of California, Berkeley School of Public Health
| | - Eric S. Holmboe
- Eric S. Holmboe, MD, is Chief Research, Milestone Development, and Evaluation Officer, Accreditation Council for Graduate Medical Education
| | - Kathryn M. McDonald
- Kathryn M. McDonald, PhD, MM, is the Bloomberg Distinguished Professor of Health Systems, Quality, and Safety, Johns Hopkins Schools of Medicine and Nursing
| | - Lindsay Mazotti
- Lindsay Mazotti, MD, is Assistant Physician-in-Chief, Kaiser Permanente East Bay and Director, Clinical Experience/Associate Professor of Clinical Science, Kaiser Permanente School of Medicine
| | - Diane R. Rittenhouse
- Diane R. Rittenhouse, MD, MPH, is Senior Fellow, Mathematica, and Professor, University of California, San Francisco
| | - Stephen M. Shortell
- Stephen M. Shortell, PhD, MBA, MPH, is Blue Cross of California Distinguished Professor of Health Policy and Management Emeritus, Dean Emeritus, and Professor, Graduate School, University of California, Berkeley School of Public Health
| | - Michael H. Kanter
- Michael H. Kanter, MD, is Chair and Professor of Clinical Science, Kaiser Permanente School of Medicine
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Rodriguez HP, Ciemins EL, Rubio K, Shortell SM. Physician Practices With Robust Capabilities Spend Less On Medicare Beneficiaries Than More Limited Practices. Health Aff (Millwood) 2022; 41:414-423. [PMID: 35254927 DOI: 10.1377/hlthaff.2021.00302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.
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Affiliation(s)
- Hector P Rodriguez
- Hector P. Rodriguez , University of California Berkeley, Berkeley, California
| | | | - Karl Rubio
- Karl Rubio, University of California Berkeley
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Frehn JL, Brewster AL, Shortell SM, Rodriguez HP. Comparing health care system and physician practice influences on social risk screening. Health Care Manage Rev 2022; 47:E1-E10. [PMID: 34843185 PMCID: PMC9646465 DOI: 10.1097/hmr.0000000000000309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Health care systems can support dissemination of innovations, such as social risk screening in physician practices, but to date, no studies have examined the association of health system characteristics and practice-level adoption of social risk screening. PURPOSE The aim of the study was to examine the association of multilevel organizational capabilities and adoption of social risk screening among system-owned physician practices. METHODOLOGY Secondary analyses of the 2018 National Survey of Healthcare Organizations and Systems were conducted. Multilevel linear regression models examined physician practice and system characteristics associated with practice adoption of screening for five social risks (food insecurity, housing instability, utility needs, interpersonal violence, and transportation needs), accounting for clustering of practices within systems using random effects. RESULTS System-owned practices screened for an average of 1.7 of the five social risks assessed. The intraclass correlation indicated 16% of practice variation in social risk screening was attributable to differences between their health systems owners, with 84% attributable to differences between individual practices. Practices owned by systems with multiple hospitals screened for an additional 0.44 social risks (p = .046) relative to practices of systems without hospitals. Practice characteristics associated with social risk screening included health information technology capacity (β = 0.20, p = .005), innovation culture (β = 0.26, p < .001), and patient engagement strategies (β = 0.57, p < .001). CONCLUSIONS Health care system capabilities account for less variation in physician practice adoption of social risk screening compared to practice-level capabilities. PRACTICE IMPLICATIONS Efforts to expand social risk screening among system-owned physician practices should focus on supporting practice capabilities, including enhancing health information technology, promoting an innovative organizational culture, and advancing patient engagement strategies.
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Tierney AA, Shortell SM, Rundall TG, Blodgett JC, Reponen E. Examining the Relationship Between the Lean Management System and Quality Improvement Care Management Processes. Qual Manag Health Care 2022; 31:1-6. [PMID: 34459445 PMCID: PMC8881543 DOI: 10.1097/qmh.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The United States has an underperforming health care system on both cost and quality criteria in comparison with other developed countries. One approach to improving system performance on both cost and quality is to use the Lean Management System based on the Shingo principles originally developed by Toyota in Japan. Our objective was to examine the association between hospital use of the Lean Management System and evidence-based or recommended quality improvement care management processes. METHODS A cross-sectional analysis of data from 223 hospitals that responded to both the 2017 National Survey of Healthcare Organizations and Systems and the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals was conducted. RESULTS Controlling for hospital organizational and market characteristics, the number of years using Lean was positively associated with use of electronic health record-based decision support, use of quality-focused information management, use of evidence-based guidelines, and support for care transitions at the P < .05 level. The degree of education and training in Lean methods and processes was also positively associated ( P < .05) with greater support for care transitions. The number of years using Lean was marginally associated with screening for clinical conditions at the P < .10 level. There was an unexpected negative association between education and training scores and screening for clinical conditions. CONCLUSIONS Greater experience in using the Lean Management System is positively associated with several evidence-based and/or recommended quality improvement care management processes.
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Affiliation(s)
- Aaron A. Tierney
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley
| | - Stephen M. Shortell
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley
| | - Thomas G. Rundall
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley
| | - Janet C. Blodgett
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley
| | - Elina Reponen
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley
- Department of Perioperative, Intensive Care, and Pain Medicine and Central Lean Improvement Office, HUS Helsinki University Hospital
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Reponen E, Jokela R, Blodgett JC, Rundall TG, Shortell SM, Nuutinen M, Skants N, Mäkijärvi M, Torkki P. Validation of the Lean Healthcare Implementation Self-Assessment Instrument (LHISI) in the finnish healthcare context. BMC Health Serv Res 2021; 21:1289. [PMID: 34852808 PMCID: PMC8638099 DOI: 10.1186/s12913-021-07322-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 11/18/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lean management is growing in popularity in the healthcare sector worldwide, yet healthcare organizations are struggling with assessing the maturity of their Lean implementation and monitoring its change over time. Most existing methods for such assessments are time consuming, require site visits by external consultants, and lack frontline involvement. The original Lean Healthcare Implementation Self-Assessment Instrument (LHISI) was developed by the Center for Lean Engagement and Research (CLEAR), University of California, Berkeley as a Lean principles-based survey instrument that avoids the above problems. We validated the original LHISI in the context of Finnish healthcare. METHODS The original HISI survey was sent over a secure organizational email system to the over 26,000 employees of the Hospital District of Helsinki and Uusimaa in March 2020. The data were randomly split with one part used to carry out an exploratory factor analysis (EFA), and the other for testing the resulting model using confirmatory factor analysis (CFA). RESULTS A total of 6073 employees responded to the LHISI survey, for an overall response rate of 23%. The results indicated that the 43 items used in the original LHISI can be reduced to 25 items, and these items measure a five-dimensional model of the progress of Lean implementation: leadership, commitment, standard work, communication, and daily management system. In comparison with a single-factor model, the fit measures for the 5-factor model were better: smaller X2, larger comparative fit index (CFI), smaller root mean square error of approximation (RMSEA), and smaller standardized root mean square residual (SRMR). CONCLUSIONS The 25 item LHISI is valid and feasible to use in the context of Finnish healthcare. The LHISI allows the organization to self-monitor the progress of its Lean implementation and provides the leadership with actionable knowledge to guide the path towards Lean maturity across the organization. Our findings encourage further studies on the adoption and validation of the LHISI in healthcare organizations worldwide.
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Affiliation(s)
- Elina Reponen
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA.
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland.
| | - Ritva Jokela
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland
| | - Janet C Blodgett
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Thomas G Rundall
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Stephen M Shortell
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Mikko Nuutinen
- Haartman Institute, University of Helsinki, Helsinki, Finland
| | - Noora Skants
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland
| | - Markku Mäkijärvi
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland
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Abstract
BACKGROUND AND OBJECTIVES Lean management in health care organizations attempts to empower staff to generate continuous improvement through incremental but regular improvements in work processes. However, because of the increasing pressure on health care organizations to substantially improve quality of care and patient outcomes while containing costs in the relatively short term, many health care leaders are looking for ways to achieve large breakthrough improvements in their organization's performance. The objective of this research is to understand whether and how Lean management can be used to achieve breakthrough improvements in performance. METHODS This study used grounded theory and content analysis of in-depth, semistructured interviews with 10 nationally recognized experts in the use of Lean management in health care organizations. The 10 participants constitute a purposive sample of experts with in-depth understanding of the strengths and limitations of Lean management in health care organizations. RESULTS Two out of 10 participants defined breakthrough improvement as a major change in a performance metric; 2 participants defined it as a fundamental redesign in a process or service; the remaining 6 participants defined breakthrough improvement as having both these characteristics. The extent to which participants believed Lean was an effective means for achieving breakthrough improvement in performance was related to how they defined breakthrough improvement. The 2 participants who defined breakthrough improvement as a significant change in a performance metric believed Lean methods alone were sufficient. The 2 participants who defined breakthrough improvement to be a fundamental redesign tended not to view Lean alone as an effective approach. Rather, they, and the 6 participants who defined breakthrough improvement as having both change-in-metric and process redesign characteristics, viewed human-centered design thinking as the primary or important complementary approach to achieving breakthrough improvement. Participants identified resources, culture change, and leadership commitment beyond what would be required to achieve incremental improvement as the main facilitators and barriers to achieving breakthrough improvements. CONCLUSION This research reveals some differences in experts' definitions of breakthrough improvement, and illuminates the value of human-centered design thinking, alone or as a complement to Lean management, in achieving breakthrough improvement in health care organizations. Most of our expert participants agreed that supplementing Lean management methods with the contributions of innovation design and investing significant resources, strengthening the organizational culture to support the necessary changes, and providing stronger leadership commitment to the effort are important facilitators for achieving breakthroughs in organizational performance.
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Affiliation(s)
- Christie Ahn
- Center for Lean Engagement and Research in Health Care, School of Public Health, University of California, Berkeley (Mss Ahn and Blodgett and Drs Rundall, Shortell, and Reponen); and University of Helsinki and Helsinki University Hospital, Helsinki, Finland (Dr Reponen)
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Reponen E, Rundall TG, Shortell SM, Blodgett JC, Jokela R, Mäkijärvi M, Torkki P. The cross-national applicability of lean implementation measures and hospital performance measures: a case study of Finland and the USA. Int J Qual Health Care 2021; 33:6308766. [PMID: 34165147 PMCID: PMC8886912 DOI: 10.1093/intqhc/mzab097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/04/2021] [Accepted: 06/24/2021] [Indexed: 01/16/2023] Open
Abstract
Background Health-care organizations around the world are striving to achieve
transformational performance improvement, often through adopting process
improvement methodologies such as lean management. Indeed, lean management
has been implemented in hospitals in many countries. But despite a shared
methodology and the potential benefit of benchmarking lean implementation
and its effects on hospital performance, cross-national lean benchmarking is
rare. Health-care organizations in different countries operate in very
different contexts, including different health-care system models, and these
differences may be perceived as limiting the ability of improvers to
benchmark lean implementation and related organizational performance.
However, no empirical research is available on the international relevance
and applicability of lean implementation and hospital performance measures.
To begin understanding the opportunities and limitations related to
cross-national benchmarking of lean in hospitals, we conducted a
cross-national case study of the relevance and applicability of measures of
lean implementation in hospitals and hospital performance. Methods We report an exploratory case study of the relevance of lean implementation
measures and the applicability of hospital performance measures using
quantitative comparisons of data from Hospital District of Helsinki and
Uusimaa (HUS) Helsinki University Hospital in Finland and a sample of 75
large academic hospitals in the USA. Results The relevance of lean-related measures was high across the two countries:
almost 90% of the items developed for a US survey were relevant and
available from HUS. A majority of the US-based measures for financial
performance (66.7%), service provision/utilization (100.0%)
and service provision/care processes (60.0%) were available from HUS.
Differences in patient satisfaction measures prevented comparisons between
HUS and the USA. Of 18 clinical outcome measures, only four (22%)
were not comparable. Clinical outcome measures were less affected by the
differences in health-care system models than measures related to service
provision and financial performance. Conclusions Lean implementation measures are highly relevant in health-care organizations
operating in the USA and Finland, as is the applicability of a variety of
performance improvement measures. Cross-national benchmarking in lean
healthcare is feasible, but a careful assessment of contextual factors,
including the health-care system model, and their impact on the
applicability and relevance of chosen benchmarking measures is necessary.
The differences between the US and Finnish health-care system models is most
clearly reflected in financial performance measures and care process
measures.
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Affiliation(s)
- Elina Reponen
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, 50 University Hall, Berkeley, CA, 94720-7360, USA.,HUS Helsinki University Hospital, P.O.Box 760, 00029 HUS, Finland
| | - Thomas G Rundall
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, 50 University Hall, Berkeley, CA, 94720-7360, USA
| | - Stephen M Shortell
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, 50 University Hall, Berkeley, CA, 94720-7360, USA
| | - Janet C Blodgett
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, 50 University Hall, Berkeley, CA, 94720-7360, USA
| | - Ritva Jokela
- HUS Helsinki University Hospital, P.O.Box 760, 00029 HUS, Finland
| | - Markku Mäkijärvi
- HUS Helsinki University Hospital, P.O.Box 760, 00029 HUS, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, P.O.Box 20, Helsinki 00014, Finland
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Shortell SM, Gottlieb DJ, Martinez Camblor P, O’Malley AJ. Hospital-based health systems 20 years later: A taxonomy for policy research and analysis. Health Serv Res 2021; 56:453-463. [PMID: 33429460 PMCID: PMC8143673 DOI: 10.1111/1475-6773.13621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Building on the original taxonomy of hospital-based health systems from 20 years ago, we develop a new taxonomy to inform emerging public policy and practice developments. DATA SOURCES The 2016 American Hospital Association's (AHA) Annual Survey; the 2016 IQVIA Healthcare Organizations and Systems (HCOS) database; and the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS). STUDY DESIGN Cluster analysis of the 2016 AHA Annual Survey data to derive measures of differentiation, centralization, and integration to create categories or types of hospital-based health systems. DATA COLLECTION Principal components factor analysis with varimax rotation generating the factors used in the cluster algorithms. PRINCIPAL FINDINGS Among the four cluster types, 54% (N = 202) of systems are decentralized (-0.35) and relatively less differentiated (-0.37); 23% of systems (N = 85) are highly differentiated (1.28) but relatively decentralized (-0.29); 15% (N = 57) are highly centralized (2.04) and highly differentiated (0.65); and approximately 9 percent (N = 33) are least differentiated (-1.35) and most decentralized (-0.64). Despite differences in calculation, the Highly Centralized, Highly Differentiated System Cluster and the Undifferentiated, Decentralized System Cluster were similar to those identified 20 years ago. The other two system clusters contained similarities as well as differences from those 20 years ago. Overall, 82 percent of the systems remain relatively decentralized suggesting they operate largely as holding companies allowing autonomy to individual hospitals operating within the system. CONCLUSIONS The new taxonomy of hospital-based health systems bears similarities as well as differences from 20 years ago. Important applications of the taxonomy for addressing current challenges facing the healthcare system, such as the transition to value-based payment models, continued consolidation, and the growing importance of the social determinants of health, are highlighted.
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Affiliation(s)
| | - Daniel J. Gottlieb
- The Dartmouth Institute for Health PolicyDartmouth UniversityLebanonNew HampshireUSA
| | | | - A. James O’Malley
- The Dartmouth Institute for Health PolicyDartmouth UniversityLebanonNew HampshireUSA
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Shortell SM, Blodgett JC, Rundall TG, Henke RM, Reponen E. Lean Management and Hospital Performance: Adoption vs. Implementation. Jt Comm J Qual Patient Saf 2021; 47:296-305. [PMID: 33648858 DOI: 10.1016/j.jcjq.2021.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Lean management system is being adopted and implemented by an increasing number of US hospitals. Yet few studies have considered the impact of Lean on hospitalwide performance. METHODS A multivariate analysis was performed of the 2017 National Survey of Lean/Transformational Performance Improvement in Hospitals and 2018 publicly available data from the Agency for Healthcare Research and Quality and the Center for Medicare & Medicaid Services on 10 quality/appropriateness of care, cost, and patient experience measures. RESULTS Hospital adoption of Lean was associated with higher Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient experience scores (b = 3.35, p < 0.0001) on a scale of 100-300 but none of the other 9 performance measures. The degree of Lean implementation measured by the number of units throughout the hospital using Lean was associated with lower adjusted inpatient expense per admission (b = -38.67; p < 0.001), lower 30-day unplanned readmission rate (b = -0.01, p < 0.007), a score above the national average on appropriate use of imaging-a measure of low-value care (odds ratio = 1.04, p < 0.042), and higher HCAHPS patient experience scores (b = 0.12, p < 0.012). The degree of Lean implementation was not associated with any of the other 6 performance measures. CONCLUSION Lean is an organizationwide sociotechnical performance improvement system. As such, the actual degree of implementation throughout the organization as opposed to mere adoption is, based on the present findings, more likely to be associated with positive hospital performance on at least some measures.
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Kim JG, Rodriguez HP, Shortell SM, Fuller B, Holmboe ES, Rittenhouse DR. Factors Associated With Family Medicine and Internal Medicine First-Year Residents' Ambulatory Care Training Time. Acad Med 2021; 96:433-440. [PMID: 32496285 DOI: 10.1097/acm.0000000000003522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Despite the importance of training in ambulatory care settings for residents to acquire important competencies, little is known about the organizational and environmental factors influencing the relative amount of time primary care residents train in ambulatory care during residency. The authors examined factors associated with postgraduate year 1 (PGY-1) residents' ambulatory care training time in Accreditation Council for Graduate Medical Education (ACGME)-accredited primary care programs. METHOD U.S.-accredited family medicine (FM) and internal medicine (IM) programs' 2016-2017 National Graduate Medical Education (GME) Census data from 895 programs within 550 sponsoring institutions (representing 13,077 PGY-1s) were linked to the 2016 Centers for Medicare and Medicaid Services Cost Reports and 2015-2016 Area Health Resource File. Multilevel regression models examined the association of GME program characteristics, sponsoring institution characteristics, geography, and environmental factors with PGY-1 residents' percentage of time spent in ambulatory care. RESULTS PGY-1 mean (standard deviation, SD) percent time spent in ambulatory care was 25.4% (SD, 0.4) for both FM and IM programs. In adjusted analyses (% increase [standard error, SE]), larger faculty size (0.03% [SE, 0.01], P < .001), sponsoring institution's receipt of Teaching Health Center (THC) funding (6.6% (SE, 2.7), P < .01), and accreditation warnings (4.8% [SE, 2.5], P < .05) were associated with a greater proportion of PGY-1 time spent in ambulatory care. Programs caring for higher proportions of Medicare beneficiaries spent relatively less time in ambulatory care (< 0.5% [SE, 0.2], P < .01). CONCLUSIONS Ambulatory care time for PGY-1s varies among ACGME-accredited primary care residency programs due to the complex context and factors primary care GME programs operate under. Larger ACGME-accredited FM and IM programs and those receiving federal THC GME funding had relatively more PGY-1 time spent in ambulatory care settings. These findings inform policies to increase resident exposure in ambulatory care, potentially improving learning, competency achievement, and primary care access.
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Affiliation(s)
- Jung G Kim
- J.G. Kim is lecturer, University of California, Berkeley School of Public Health, Berkeley, California, and Kaiser Permanente Bernard J. Tyson School of Medicine, Department of Health Systems Science, Pasadena, California
| | - Hector P Rodriguez
- H.P. Rodriguez is Henry J. Kaiser Endowed Chair in Organized Health Systems and professor, University of California, Berkeley School of Public Health, Berkeley, California
| | - Stephen M Shortell
- S.M. Shortell is Blue Cross of California Distinguished Professor of Health Policy and Management Emeritus, Dean Emeritus, and professor, Graduate School, University of California, Berkeley School of Public Health, Berkeley, California
| | - Bruce Fuller
- B. Fuller is professor, Education and Public Policy, University of California, Berkeley, California
| | - Eric S Holmboe
- E.S. Holmboe is chief research, milestones development, and evaluation officer, Accreditation Council for Graduate Medical Education, Chicago, Illinois
| | - Diane R Rittenhouse
- D.R. Rittenhouse is a senior fellow, Mathematica, and professor, University of California, San Francisco, California
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Reponen E, Rundall TG, Shortell SM, Blodgett JC, Juarez A, Jokela R, Mäkijärvi M, Torkki P. Benchmarking outcomes on multiple contextual levels in lean healthcare: a systematic review, development of a conceptual framework, and a research agenda. BMC Health Serv Res 2021; 21:161. [PMID: 33607988 PMCID: PMC7893761 DOI: 10.1186/s12913-021-06160-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 02/08/2021] [Indexed: 12/21/2022] Open
Abstract
Background Reliable benchmarking in Lean healthcare requires widely relevant and applicable domains for outcome metrics and careful attention to contextual levels. These levels have been poorly defined and no framework to facilitate performance benchmarking exists. Methods We systematically searched the Pubmed, Scopus, and Web of Science databases to identify original articles reporting benchmarking on different contextual levels in Lean healthcare and critically appraised the articles. Scarcity and heterogeneity of articles prevented quantitative meta-analyses. We developed a new, widely applicable conceptual framework for benchmarking drawing on the principles of ten commonly used healthcare quality frameworks and four value statements, and suggest an agenda for future research on benchmarking in Lean healthcare. Results We identified 22 articles on benchmarking in Lean healthcare on 4 contextual levels: intra-organizational (6 articles), regional (4), national (10), and international (2). We further categorized the articles by the domains in the proposed conceptual framework: patients (6), employed and affiliated staff (2), costs (2), and service provision (16). After critical appraisal, only one fifth of the articles were categorized as high quality. Conclusions When making evidence-informed decisions based on current scarce literature on benchmarking in healthcare, leaders and managers should carefully consider the influence of context. The proposed conceptual framework may facilitate performance benchmarking and spreading best practices in Lean healthcare. Future research on benchmarking in Lean healthcare should include international benchmarking, defining essential factors influencing Lean initiatives on different levels of context; patient-centered benchmarking; and system-level benchmarking with a balanced set of outcomes and quality measures.
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Affiliation(s)
- Elina Reponen
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA. .,HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland.
| | - Thomas G Rundall
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Stephen M Shortell
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Janet C Blodgett
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Angelica Juarez
- Center for Lean Engagement and Research in Healthcare, School of Public Health, University of California, Berkeley, California, USA
| | - Ritva Jokela
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland
| | - Markku Mäkijärvi
- HUS Helsinki University Hospital, P.O.Box 760, 00029, Helsinki, Finland
| | - Paulus Torkki
- Department of Public Health, University of Helsinki, Helsinki, Finland
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24
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Fisher ES, Shortell SM, O'Malley AJ, Fraze TK, Wood A, Palm M, Colla CH, Rosenthal MB, Rodriguez HP, Lewis VA, Woloshin S, Shah N, Meara E. Financial Integration's Impact On Care Delivery And Payment Reforms: A Survey Of Hospitals And Physician Practices. Health Aff (Millwood) 2020; 39:1302-1311. [PMID: 32744948 PMCID: PMC7849626 DOI: 10.1377/hlthaff.2019.01813] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Health systems continue to grow in size. Financial integration-the ownership of hospitals or physician practices-often has anticompetitive effects that contribute to the higher prices for health care seen in the US. To determine whether the potential harms of financial integration are counterbalanced by improvements in quality, we surveyed nationally representative samples of hospitals (n = 739) and physician practices (n = 2,189), stratified according to whether they were independent or were owned by complex systems, simple systems, or medical groups. The surveys included nine scales measuring the level of adoption of diverse, quality-focused care delivery and payment reforms. Scores varied widely across hospitals and practices, but little of this variation was explained by ownership status. Quality scores favored financially integrated systems for four of nine hospital measures and one of nine practice measures, but in no case favored complex systems. Greater financial integration was generally not associated with better quality.
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Affiliation(s)
- Elliott S Fisher
- Elliott S. Fisher is a professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, in Lebanon, New Hampshire
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management Emeritus and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at the University of California Berkeley, in Berkeley, California
| | - A James O'Malley
- A. James O'Malley is a professor of biostatistics at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | - Taressa K Fraze
- Taressa K. Fraze is an assistant professor in the Department of Community and Family Medicine at the University of California San Francisco, in San Francisco, California
| | - Andrew Wood
- Andrew Wood is a research associate at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | - Marisha Palm
- Marisha Palm is a research associate in the Department of Medicine, Tufts Medical Center, in Boston, Massachusetts
| | - Carrie H Colla
- Carrie H. Colla is a professor at the Dartmouth Institute for Health Policy and Clinical Practice in the Geisel School of Medicine at Dartmouth
| | - Meredith B Rosenthal
- Meredith B. Rosenthal is the C. Boyden Gray Professor of Health Economics and Policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Hector P Rodriguez
- Hector P. Rodriguez is the Henry J. Kaiser Professor of Health Policy and Management, director of the California Initiative for Health Equity and Action, and codirector of the Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California Berkeley
| | - Valerie A Lewis
- Valerie A. Lewis is an associate professor of health policy and management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, in Chapel Hill, North Carolina
| | - Steven Woloshin
- Steven Woloshin is a professor at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth
| | - Nilay Shah
- Nilay Shah is a professor at the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, in Rochester, Minnesota
| | - Ellen Meara
- Ellen Meara is a professor of health economics and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health; an adjunct professor of health policy and clinical practice at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth; and a research associate at the National Bureau of Economic Research in Cambridge, Massachusetts
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25
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Furukawa MF, Machta RM, Barrett KA, Jones DJ, Shortell SM, Scanlon DP, Lewis VA, O’Malley AJ, Meara ER, Rich EC. Landscape of Health Systems in the United States. Med Care Res Rev 2020; 77:357-366. [PMID: 30674227 PMCID: PMC7187756 DOI: 10.1177/1077558718823130] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite the prevalence of vertical integration, data and research focused on identifying and describing health systems are sparse. Until recently, we lacked an enumeration of health systems and an understanding of how systems vary by key structural attributes. To fill this gap, the Agency for Healthcare Research and Quality developed the Compendium of U.S. Health Systems, a data resource to support research on comparative health system performance. In this article, we describe the methods used to create the Compendium and present a picture of vertical integration in the United States. We identified 626 health systems in 2016, which accounted for 70% of nonfederal general acute care hospitals. These systems varied by key structural attributes, including size, ownership, and geographic presence. The Compendium can be used to study the characteristics of the U.S. health care system and address policy issues related to provider organizations.
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Affiliation(s)
| | | | | | | | | | | | - Valerie A. Lewis
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
| | - A. James O’Malley
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
| | - Ellen R. Meara
- The Dartmouth Institute for Health Policy and Clinical
Practice, Lebanon, NH, USA
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26
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Comfort LN, Fulton BD, Shortell SM. Assessing the Short-Term Association Between Rural Hospitals' Participation in Accountable Care Organizations and Changes in Utilization and Financial Performance. J Rural Health 2020; 37:334-346. [PMID: 32657481 DOI: 10.1111/jrh.12494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Although much research has been done on accountable care organizations (ACOs), little is known about their impact on rural hospitals. We examine the association between rural hospitals' participation in an ACO and their performance on utilization and financial measures. METHODS This quasi-experimental study estimates the relationship between voluntary ACO participation and hospital metrics using propensity score-matched, longitudinal regression models with year and hospital fixed effects. Regression models controlled for secular trends and time-varying hospital and county characteristics. Hospital measures were from the American Hospital Association, RAND Hospital Data, and Leavitt Partners. The initial population comprises 643 rural hospitals that participated in an ACO for at least one year during the 2011 to 2018 study period and 1,541 rural hospitals that did not participate in an ACO. From this population we created a sample of propensity score-matched hospitals consisting of 525 ACO-participating and 525 comparable non-ACO hospitals. RESULTS Rural hospitals' participation in an ACO is not associated with changes in hospital utilization or financial measures, nor is there an association between these performance metrics and whether another within-county hospital participated in an ACO. A secondary analysis limited to Critical Access Hospitals provides some evidence that inpatient utilization increases in the second year of ACO participation, though the increases are not significant in year 3 and beyond. CONCLUSION We find no evidence that rural hospitals experience substantive changes in outpatient visits, inpatient utilization, or operating margin in the years immediately after joining an ACO.
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Affiliation(s)
- Leeann N Comfort
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Brent D Fulton
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
| | - Stephen M Shortell
- Department of Health Policy and Management, University of California, Berkeley, Berkeley, California
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27
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Harrison MI, Shortell SM. Multi-level analysis of the learning health system: Integrating contributions from research on organizations and implementation. Learn Health Syst 2020; 5:e10226. [PMID: 33889735 PMCID: PMC8051352 DOI: 10.1002/lrh2.10226] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/11/2020] [Accepted: 03/08/2020] [Indexed: 11/08/2022] Open
Abstract
Introduction Organizations and systems that deliver health care may better adapt to rapid change in their environments by acting as learning organizations and learning health systems (LHSs). Despite widespread recognition that multilevel forces shape capacity for learning within care delivery organizations, there is no agreed-on, comprehensive, multilevel framework to inform LHS research and practice. Methods We develop such a framework, which can enhance both research on LHSs and practical steps toward their development. We draw on existing frameworks and research within organization and implementation science and synthesize contributions from three influential frameworks: the Consolidated Framework for Implementation Research, the social-ecological framework, and the organizational change framework. These frameworks come, respectively, from the fields of implementation science, public health, and organization science. Results Our proposed integrative framework includes both intraorganizational levels (individual, team, mid-management, organization) and the operating and general environments in which delivery organizations operate. We stress the importance of examining interactions among influential factors both within and across system levels and focus on the effects of leadership, incentives, and culture. Additionally, we indicate that organizational learning depends substantially on internal and cross-level alignment of these factors. We illustrate the contribution of our multilevel perspective by applying it to the analysis of three diverse implementation initiatives that aimed at specific care improvements and enduring system learning. Conclusions The framework and perspective developed here can help investigators and practitioners broadly scan and then investigate forces influencing improvement and learning and may point to otherwise unnoticed interactions among influential factors. The framework can also be used as a planning tool by managers and practitioners.
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Affiliation(s)
- Michael I Harrison
- Senior Social Scientist Agency for Healthcare Research and Quality Rockville Maryland USA
| | - Stephen M Shortell
- Professor of the Graduate School, Blue Cross of California Distinguished Professor of Health Policy and Management, Emeritus; Professor of Organization Behavior, Emeritus School of Public Health and Haas School of Business, University of California - Berkeley Berkeley California USA
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28
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Kandel ZK, Rittenhouse DR, Bibi S, Fraze TK, Shortell SM, Rodríguez HP. The CMS State Innovation Models Initiative and Improved Health Information Technology and Care Management Capabilities of Physician Practices. Med Care Res Rev 2020; 78:350-360. [PMID: 31967494 DOI: 10.1177/1077558719901217] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Centers for Medicare and Medicaid Services' (CMS) State Innovation Models (SIMs) initiative funded 17 states to implement health care payment and delivery system reforms to improve health system performance. Whether SIM improved health information technology (HIT) and care management capabilities of physician practices, however, remains unclear. National surveys of physician practices (N = 2,722) from 2012 to 2013 and 2017 to 2018 were linked. Multivariable regression estimated differential adoption of 10 HIT functions and chronic care management processes (CMPs) based on SIM award status (SIM Round 1, SIM Round 2, or non-SIM). HIT and CMP capabilities improved equally for practices in SIM Round 1 (5.3 vs. 6.8 capabilities, p < .001), SIM Round 2 (4.7 vs. 7.0 capabilities, p < .001), and non-SIM (4.2 vs. 6.3 capabilities, p < .001) states. The CMS SIM Initiative did not accelerate the adoption of ten foundational physician practice capabilities beyond national trends.
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Affiliation(s)
| | - Diane R Rittenhouse
- University of California, Berkeley, CA, USA.,University of California, San Francisco, CA, USA
| | - Salma Bibi
- University of California, Berkeley, CA, USA
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29
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Hurley VB, Wang Y, Rodriguez HP, Shortell SM, Kearing S, Savitz LA. Decision Aid Implementation and Patients' Preferences for Hip and Knee Osteoarthritis Treatment: Insights from the High Value Healthcare Collaborative. Patient Prefer Adherence 2020; 14:23-32. [PMID: 32021114 PMCID: PMC6954078 DOI: 10.2147/ppa.s227207] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/07/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) research has emphasized the role of decision aids (DAs) for helping patients make treatment decisions reflective of their preferences, yet there have been few collaborative multi-institutional efforts to integrate DAs in orthopedic consultations and primary care encounters. OBJECTIVE In the context of routine DA implementation for SDM, we investigate which patient-level characteristics are associated with patient preferences for surgery versus medical management before and after exposure to DAs. We explored whether DA implementation in primary care encounters was associated with greater shifts in patients' treatment preferences after exposure to DAs compared to DA implementation in orthopedic consultations. DESIGN Retrospective cohort study. SETTING 10 High Value Healthcare Collaborative (HVHC) health systems. STUDY PARTICIPANTS A total of 495 hip and 1343 adult knee osteoarthritis patients who were exposed to DAs within HVHC systems between July 2012 to June 2015. RESULTS Nearly 20% of knee patients and 17% of hip patients remained uncertain about their treatment preferences after viewing DAs. Older patients and patients with high pain levels had an increased preference for surgery. Older patients receiving DAs from three HVHC systems that transitioned DA implementation from orthopedics into primary care had lower odds of preferring surgery after DA exposure compared to older patients in seven HVHC systems that only implemented DAs for orthopedic consultations. CONCLUSION Patients' treatment preferences were largely stable over time, highlighting that DAs for SDM largely do not necessarily shift preferences. DAs and SDM processes should be targeted at older adults and patients reporting high pain levels. Initiating treatment conversations in primary versus specialty care settings may also have important implications for engagement of patients in SDM via DAs.
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Affiliation(s)
- Vanessa B Hurley
- Health Systems Administration, Georgetown University, Washington, DC20057, USA
| | | | - Hector P Rodriguez
- Health Policy and Management, University of California, Berkeley School of Public Health, Berkeley, CA94720, USA
| | - Stephen M Shortell
- Health Policy and Management, University of California, Berkeley School of Public Health, Berkeley, CA94720, USA
| | | | - Lucy A Savitz
- Center for Health Research (Northwest and Hawaii), Health Research, Kaiser Permanente, Portland, OR97227, USA
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30
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Abstract
Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.
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Affiliation(s)
- Vanessa B Hurley
- Vanessa B. Hurley ( vh151@georgetown. edu ) is an assistant professor of Health Systems Administration at the Georgetown University School of Nursing and Health Studies, in Washington, D.C
| | - Hector P Rodriguez
- Hector P. Rodriguez is the Henry J. Kaiser Professor of Health Policy and Management and codirector of the Center for Healthcare Organizational and Innovation Research, both at the University of California (UC) Berkeley School of Public Health
| | - Stephen Kearing
- Stephen Kearing is a Reporting and Analytics programmer at the High Value Healthcare Collaborative, in Hanover, New Hampshire
| | - Yue Wang
- Yue Wang is a data analyst in the Center for Healthcare Organizational and Innovation Research, UC Berkeley School of Public Health
| | - Ming D Leung
- Ming D. Leung is an associate professor of organization and management at the UC Irvine Paul Merage School of Business
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor Emeritus of Health Policy and Management, a professor of organization behavior at the School of Public Health and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at UC Berkeley
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31
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Enthoven A, Fuchs VR, Shortell SM. To Control Costs Expand Managed Care and Managed Competition. JAMA 2019; 322:2075-2076. [PMID: 31697334 DOI: 10.1001/jama.2019.17147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | - Victor R Fuchs
- Stanford Institute for Economic Policy Research, Stanford University, Stanford, California
| | - Stephen M Shortell
- Division of Health Policy and Management, University of California, Berkeley School of Public Health, Berkeley
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32
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Rodriguez HP, Poon BY, Wang E, Shortell SM. Linking Practice Adoption of Patient Engagement Strategies and Relational Coordination to Patient-Reported Outcomes in Accountable Care Organizations. Milbank Q 2019; 97:692-735. [PMID: 31206824 DOI: 10.1111/1468-0009.12400] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Policy Points Accountable care organizations (ACOs) have incentives to promote the adoption of patient engagement strategies such as shared decision making and self-management support programs to improve patient outcomes and contain health care costs. High adoption of patient engagement strategies among ACO-affiliated practices did not improve patient-reported outcomes (PROs) of physical, emotional, and social function among adult patients with diabetes and/or cardiovascular disease over a one-year time frame, likely because implementing these strategies requires extensive clinician and staff training, workflow redesign, and patient participation over time. A dominant focus on improving clinical measures to meet external requirements may crowd out time needed for care team members to address other outcomes that matter to patients, including PROs. Payers and policy-makers should explicitly incentivize the collection and use of PROs when contracting with ACOs. CONTEXT Adult primary care practices of accountable care organizations (ACOs) are adopting a range of patient engagement strategies, but little is known about how these strategies are related to patient-reported outcomes (PROs) and how relational coordination among team members aids implementation. METHODS We used a mixed-methods cohort study design integrating administrative and clinical data with two data collection waves (2014-2015 and 2016-2017) of clinician and staff surveys (n = 764), surveys of adult patients with diabetes and/or cardiovascular disease (CVD) (n = 1,276), and key informant interviews of clinicians, staff, and administrators (n = 103). Multivariable linear regression estimated the relationship of practice adoption of patient engagement strategies, relational coordination, and PROs of physical, social, and emotional function. The mediating role of patient activation was examined using cross-lagged panel models. Key informant interviews assessed how relational coordination influences the implementation of patient engagement strategies. FINDINGS There were no differential improvements in PROs among patients of practices with high vs. low adoption of patient engagement strategies or among patients of practices with high vs. low relational coordination. The Patient Activation Measure (PAM) is strongly related to better physical, emotional, and social PROs over time. Relational coordination facilitated the implementation of patient engagement strategies, but key informants indicated that resources and systems to systematically track treatment preferences and goals beyond clinical indicators were needed to support effective implementation. CONCLUSIONS Adult patients with diabetes and/or CVD of ACO-affiliated practices with high adoption of patient engagement strategies do not have improved PROs of physical, emotional, and social function over a one-year time frame. Implementing patient engagement strategies increases task interdependence among primary care team members, which needs to be carefully managed. ACOs may need to make greater investment in collecting, monitoring, and analyzing PRO data to ensure that practice adoption and implementation of patient engagement strategies leads to improved physical, emotional, and social function among patients.
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Affiliation(s)
- Hector P Rodriguez
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley.,Division of Health Policy and Management, UC Berkeley School of Public Health
| | - Bing Ying Poon
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley
| | - Emily Wang
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley
| | - Stephen M Shortell
- Center for Healthcare Organizational and Innovation Research, University of California, Berkeley.,Division of Health Policy and Management, UC Berkeley School of Public Health
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33
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Fremont A, Kim AY, Bailey K, Hanley HR, Thorne C, Dudl RJ, Kaplan RM, Shortell SM, DeMaria AN. One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability In San Diego County Collaborative. Health Aff (Millwood) 2019; 37:1457-1465. [PMID: 30179541 DOI: 10.1377/hlthaff.2018.0443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Before 2011 rates of hospitalization for heart attacks were about the same in San Diego County as they were in the rest of California. In 2011 a multistakeholder population health collaborative consisting of partners at the federal, state, and local levels launched Be There San Diego. The collaborative's goal was to reduce cardiovascular events through the spread of best practices aimed at improving control of hypertension, lipid levels, and blood sugar and through patient and medical community activation. Using hospital discharge data for the period 2007-16, we compared acute myocardial infarction (AMI) hospitalization rates in San Diego County and the rest of the state before and after the demonstration project started. AMI hospitalization rates decreased by 22 percent in San Diego County versus 8 percent in the rest of the state, with an estimated 3,826 AMI hospitalizations avoided and $86 million in savings in San Diego. Results show that a science-based health collaborative can improve outcomes while lowering costs, and efforts are under way to ensure the collaborative's sustainability.
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Affiliation(s)
- Allen Fremont
- Allen Fremont is a natural scientist and sociologist at the RAND Corporation in Santa Monica, California
| | - Alice Y Kim
- Alice Y. Kim is a policy analyst at the RAND Corporation
| | - Katherine Bailey
- Katherine Bailey is CEO of the San Diego Healthcare Quality Collaborative, in Encinitas, California
| | - Hattie Rees Hanley
- Hattie Rees Hanley is director of the Right Care Initiative, Center for Health Outcomes and Innovation Research, University of California Berkeley School of Public Health
| | - Christine Thorne
- Christine Thorne is medical director for family medicine and public health of Be There San Diego, in California
| | - R James Dudl
- R. James Dudl is clinical lead for diabetes at the Care Management Institute and Kaiser Permanente Community Health, in Oakland, California
| | - Robert M Kaplan
- Robert M. Kaplan is director of research at the Clinical Excellence Research Center (CERC), Stanford University School of Medicine, in California
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor Emeritus of Health Policy and Management, a professor of organization behavior at the School of Public Health and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at the University of California Berkeley
| | - Anthony N DeMaria
- Anthony N. DeMaria ( ) is the Judy and Jack White Chair in Cardiology and a professor of internal medicine, University of California San Diego, in La Jolla
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Lewis VA, D'Aunno T, Murray GF, Shortell SM, Colla CH. The Hidden Roles That Management Partners Play In Accountable Care Organizations. Health Aff (Millwood) 2019; 37:292-298. [PMID: 29401012 DOI: 10.1377/hlthaff.2017.1025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) are often discussed and promoted as driven by physicians, hospitals, and other health care providers. However, because of the flexible nature of ACO contracts, management organizations may also become partners in ACOs. We used data from 2013-15 on 276 ACOs from the National Survey of Accountable Care Organizations to understand the prevalence of nonprovider management partners' involvement in ACOs, the services these partners provide, and the structure of ACOs that have such partners. We found that 37 percent of ACOs reported having a management partner, and two-thirds of these ACOs reported that the partner shared in the financial risks or rewards. Among ACOs with partners, 94 percent had data services provided by the partner, 87 percent received administrative services, 68 percent received educational services, and 66 percent received care coordination services. Half received all four of these services from their partner. ACOs with partners were more heavily primary care than other ACOs. ACOs with and without partners had similar performance on costs and quality in Medicare ACO programs. Our findings suggest that management partners play a central role in many ACOs, perhaps supplying smaller and physician-run ACOs with services or expertise perceived as necessary for ACO success.
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Affiliation(s)
- Valerie A Lewis
- Valerie A. Lewis ( ) is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire
| | - Thomas D'Aunno
- Thomas D'Aunno is a professor of management and director of the Health Policy and Management Program at the Robert F. Wagner Graduate School of Public Service, New York University, in New York City
| | - Genevra F Murray
- Genevra F. Murray is a research project director at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor Emeritus of Health Policy and Management, a professor of organization behavior at the School of Public Health and Professor of the Graduate School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus at the School of Public Health, all at the University of California, Berkeley
| | - Carrie H Colla
- Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
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Norton PT, Rodriguez HP, Shortell SM, Lewis VA. Organizational influences on healthcare system adoption and use of advanced health information technology capabilities. Am J Manag Care 2019; 25:e21-e25. [PMID: 30667614 PMCID: PMC6581444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The adoption of advanced health information technology (HIT) capabilities, such as predictive analytic functions and patient access to records, remains variable among healthcare systems across the United States. This study is the first to identify characteristics that may drive this variability among health systems. STUDY DESIGN Responses from the 2017/2018 National Survey of Healthcare Organizations and Systems were used to assess the extent to which healthcare system organizational structure, electronic health record (EHR) standardization, and resource allocation practices were associated with use of 5 advanced HIT capabilities. Of 732 systems surveyed, 446 responded (60.9%), 425 (58.1%) met sample inclusion criteria, and 389 (53.1%) reported consistent EHR use. METHODS Measures of adoption, resource allocation, and organizational structure were developed based on survey responses. Multivariate linear regression with control variables estimated the relationships. RESULTS Adoption of advanced HIT capabilities is low and variable, with a mean of 2.4 capabilities adopted and only 8.4% of systems reporting widespread adoption of all 5 capabilities. In adjusted analyses, EHR standardization (β = 0.76; P = .001) was the strongest predictor of the number of advanced capabilities adopted, and ownership and management of medical groups (β = 0.32; P = .04) was also a significant predictor. CONCLUSIONS Health systems that standardize their EHRs and that own and manage hospitals and medical groups have higher rates of advanced HIT adoption and use. System leaders looking to increase the use of advanced HIT capabilities should consider ways to better standardize their EHRs across organizations.
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Affiliation(s)
- Paul T Norton
- School of Public Health, University of California Berkeley, 2121 Berkeley Way, Berkeley, CA 94704.
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Casalino LP, Ramsay P, Baker LC, Pesko MF, Shortell SM. Medical Group Characteristics and the Cost and Quality of Care for Medicare Beneficiaries. Health Serv Res 2018; 53:4970-4996. [PMID: 29978481 PMCID: PMC6232442 DOI: 10.1111/1475-6773.13010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To estimate the relationship between outcomes of care and medical practices' structure and use of organized care improvement processes. DATA SOURCES/STUDY SETTING We linked Medicare claims data to our national survey of physician practices (2012-2013). Fifty percent response rate; 1,040 responding practices; 31,888 physicians; 868,213 attributed Medicare beneficiaries. STUDY DESIGN Cross-sectional observational analysis of the relationship between practice characteristics and total spending, readmissions, and ambulatory care-sensitive admissions (ACSAs), for all beneficiaries and five categories of beneficiary defined by predicted need for care. PRINCIPAL FINDINGS Practices with 100+ physicians and 50-99 physicians had, respectively, annual spending per high-need beneficiary that was $1,870 (12.5 percent) and $1,824 higher than practices with 1-2 physicians, and readmission rates 1.64 and 1.71 higher. ACSA rates did not vary significantly by practice size. Outcomes did not vary significantly by ownership or by practices' use of organized processes to improve care. CONCLUSIONS Large practices had higher spending and readmission rates than the smallest practices, especially for high-need beneficiaries. There were no significant performance differences between physician-owned and hospital-owned practices. Policy makers should consider the effects of specific policies on provider organization, pending further research to learn which types of practice provide better care.
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Affiliation(s)
- Lawrence P. Casalino
- Division of Health Policy and EconomicsDepartment of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Patricia Ramsay
- Center for Healthcare Organizational and Innovation Research (CHOIR)School of Public HealthUniversity of California—BerkeleyBerkeleyCA
| | - Laurence C. Baker
- Department of Health Research and Policy and the Stanford
Institute for Economic Policy ResearchStanfordCA
| | - Michael F. Pesko
- Department of EconomicsAndrew Young School of Policy StudiesGeorgia State UniversityAtlantaGA
| | - Stephen M. Shortell
- Center for Healthcare Organizational and Innovation Research (CHOIR)School of Public Health, and the Haas School of BusinessUniversity of CaliforniaBerkeleyCA
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Baker LC, Pesko M, Ramsay P, Casalino LP, Shortell SM. Are Changes in Medical Group Practice Characteristics Over Time Associated With Medicare Spending and Quality of Care? Med Care Res Rev 2018; 77:402-415. [PMID: 30465626 DOI: 10.1177/1077558718812939] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Physician practices have been growing in size, and becoming more commonly owned by hospitals, over time. We use survey data on physician practices surveyed at two points in time, linked to Medicare claims data, to investigate whether changes in practice size or ownership are associated with changes in the use of care management, health information technology (HIT), or quality improvement processes. We find that practice growth and becoming hospital-owned are associated with adoption of more quality improvement processes, but not with care management or HIT. We then investigate whether growth or becoming hospital-owned are associated with changes in Medicare spending, 30-day readmission rates, or ambulatory care sensitive admission rates. We find little evidence for associations with practice size and ownership, but the use of care management practices is associated with lower rates of ambulatory care sensitive admissions.
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Affiliation(s)
- Laurence C Baker
- Stanford University School of Medicine, Stanford, CA, USA.,National Bureau of Economic Research, Cambridge, MA, USA
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Mishra MK, Saunders CH, Rodriguez HP, Shortell SM, Fisher E, Elwyn G. How do healthcare professionals working in accountable care organisations understand patient activation and engagement? Qualitative interviews across two time points. BMJ Open 2018; 8:e023068. [PMID: 30385443 PMCID: PMC6252703 DOI: 10.1136/bmjopen-2018-023068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE If patient engagement is the new 'blockbuster drug' why are we not seeing spectacular effects? Studies have shown that activated patients have improved health outcomes, and patient engagement has become an integral component of value-based payment and delivery models, including accountable care organisations (ACO). Yet the extent to which clinicians and managers at ACOs understand and reliably execute patient engagement in clinical encounters remains unknown. We assessed the use and understanding of patient engagement approaches among frontline clinicians and managers at ACO-affiliated practices. DESIGN Qualitative study; 103 in-depth, semi-structured interviews. PARTICIPANTS Sixty clinicians and eight managers were interviewed at two established ACOs. APPROACH We interviewed healthcare professionals about their awareness, attitudes, understanding and experiences of implementing three key approaches to patient engagement and activation: 1) goal-setting, 2) motivational interviewing and 3) shared decision making. Of the 60 clinicians, 33 were interviewed twice leading to 93 clinician interviews. Of the 8 managers, 2 were interviewed twice leading to 10 manager interviews. We used a thematic analysis approach to the data. KEY RESULTS Interviewees recognised the term 'patient activation and engagement' and had favourable attitudes about the utility of the associated skills. However, in-depth probing revealed that although interviewees reported that they used these patient activation and engagement approaches, they have limited understanding of these approaches. CONCLUSIONS Without understanding the concept of patient activation and the associated approaches of shared decision making and motivational interviewing, effective implementation in routine care seems like a distant goal. Clinical teams in the ACO model would benefit from specificity defining key terms pertaining to the principles of patient activation and engagement. Measuring the degree of understanding with reward that are better-aligned for behaviour change will minimise the notion that these techniques are already being used and help fulfil the potential of patient-centred care.
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Affiliation(s)
- Manish K Mishra
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Catherine H Saunders
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Hector P Rodriguez
- Berkeley School of Public Health, University of California, Berkeley, California, USA
| | - Stephen M Shortell
- Berkeley School of Public Health, University of California, Berkeley, California, USA
| | - Elliott Fisher
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Glyn Elwyn
- The Dartmouth Institute of Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Watterson JL, Rodriguez HP, Shortell SM, Aguilera A. Improved Diabetes Care Management Through a Text-Message Intervention for Low-Income Patients: Mixed-Methods Pilot Study. JMIR Diabetes 2018; 3:e15. [PMID: 30377141 PMCID: PMC6238849 DOI: 10.2196/diabetes.8645] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 03/22/2018] [Accepted: 08/14/2018] [Indexed: 12/02/2022] Open
Abstract
Background Diabetes is a major contributor to global death and disability. Text-messaging interventions hold promise for improving diabetes outcomes through better knowledge and self-management. Objective The aim of this study was to examine the implementation and impact of a diabetes text-messaging program targeted primarily for low-income Latino patients receiving care at 2 federally qualified health centers (FQHCs). Methods A mixed-methods, quasi-experimental research design was employed for this pilot study. A total of 50 Spanish or English-speaking adult patients with diabetes attending 2 FQHC sites in Los Angeles from September 2015 to February 2016 were enrolled in a 12-week, bidirectional text-messaging program. A comparison group (n=160) was constructed from unexposed, eligible patients. Demographic data and pre/post clinical indicators were compared for both the groups. Propensity score weighting was used to reduce selection bias, and over-time differences in clinical outcomes between groups were estimated using individual fixed-effects regression models. Population-averaged linear models were estimated to assess differential effects of patient engagement on each clinical indicator among the intervention participants. A sample of intervention patients (n=11) and all implementing staff (n=8) were interviewed about their experiences with the program. Qualitative data were transcribed, translated, and analyzed to identify common themes. Results The intervention group had a mean glycated hemoglobin (HbA1c) reduction of 0.4 points at follow-up, relative to the comparison group (P=.06). Patients who were more highly engaged with the program (response rate ≥median of 64.5%) experienced a 2.2 point reduction in HbA1c, relative to patients who were less engaged, controlling for demographic characteristics (P<.001). Qualitative analyses revealed that many participants felt supported, as though “someone was worrying about [their] health.” Participants also cited learning new information, setting new goals, and receiving helpful reminders. Staff and patients highlighted strategies to improve the program, including incorporating patient responses into in-person clinical care and tailoring the messages to patient knowledge. Conclusions A diabetes text-messaging program provided instrumental and emotional support for participants and may have contributed to clinically meaningful improvements in HbA1c. Patients who were more engaged demonstrated greater improvement. Program improvements, such as linkages to clinical care, hold potential for improving patient engagement and ultimately, improving clinical outcomes.
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Affiliation(s)
- Jessica L Watterson
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Hector P Rodriguez
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Stephen M Shortell
- Center for Healthcare Organizational and Innovation Research, School of Public Health, University of California, Berkeley, Berkeley, CA, United States
| | - Adrian Aguilera
- School of Social Welfare, University of California, Berkeley, Berkeley, CA, United States.,Department of Psychiatry, University of California, San Francisco, San Francisco, CA, United States
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Shortell SM, Ramsay PP, Baker LC, Pesko MF, Casalino LP. The characteristics of physician practices joining the early ACOs: looking back to look forward. Am J Manag Care 2018; 24:469-474. [PMID: 30325188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To assess whether the characteristics and capabilities of individual practices intending to join the early Medicare accountable care organization (ACO) programs differed from those of practices not intending to join. STUDY DESIGN Data from a 2012-2013 national survey of 1398 physician practices were linked to 2012 Medicare beneficiary claims data to examine differences between practices intending to join a Medicare ACO and practices not intending to join a Medicare ACO. METHODS Differences were examined with regard to patient sociodemographic characteristics and disease burden, practice characteristics and capabilities, and cost and quality measures. Logistic regression was used to examine the differences. RESULTS Practices intending to join were more likely to have better care management capabilities (odds ratio [OR], 1.72; P <.003), health information technology functionality (OR, 1.87; P <.001), and use of quality improvement methods (OR, 1.52; P <.04). They were also more likely to have had prior pay-for-performance experience (OR, 1.59; P <.02) and less likely to be physician-owned (OR, 0.51; P <.001). However, the practices with the greater capabilities still used half or less of them. CONCLUSIONS Physician practices that intended to join the early ACO programs had greater capabilities and experience to manage risk than those practices that decided not to join. The early ACO programs thus attracted the more capable physician practices, but those practices still fell short of implementing key recommended behaviors. The findings have implications for future physician practice selection into ACOs.
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Affiliation(s)
- Stephen M Shortell
- University of California, Berkeley School of Public Health, 2121 Berkeley Way, Room 5317, Berkeley, CA 94720.
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41
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Pesko MF, Ryan AM, Shortell SM, Copeland KR, Ramsay PP, Sun X, Mendelsohn JL, Rittenhouse DR, Casalino LP. Spending per Medicare Beneficiary Is Higher in Hospital-Owned Small- and Medium-Sized Physician Practices. Health Serv Res 2018; 53:2133-2146. [PMID: 28940537 PMCID: PMC6051973 DOI: 10.1111/1475-6773.12765] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine the relationship of physician versus hospital ownership of small- and medium-sized practices with spending and utilization of care. DATA SOURCE/STUDY SETTING/DATA COLLECTION Survey data for 1,045 primary care-based practices of 1-19 physicians linked to Medicare claims data for 2008 for 282,372 beneficiaries attributed to the 3,010 physicians in these practices. STUDY DESIGN We used generalized linear models to estimate the associations between practice characteristics and outcomes (emergency department visits, index admissions, readmissions, and spending). PRINCIPAL FINDINGS Beneficiaries linked to hospital-owned practices had 7.3 percent more emergency department visits and 6.4 percent higher total spending compared to beneficiaries linked to physician-owned practices. CONCLUSIONS Physician practices are increasingly being purchased by hospitals. This may result in higher total spending on care.
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Affiliation(s)
- Michael F. Pesko
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
| | - Andrew M. Ryan
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMI
| | | | | | - Patricia P. Ramsay
- Center for Healthcare Organizational and Innovation ResearchDivision of Health Policy and ManagementUniversity of California, BerkeleyBerkeleyCA
| | - Xuming Sun
- Primary Care Information ProjectNew York City Department of Health and Mental HygieneLong Island City (Queens)NY
| | | | - Diane R. Rittenhouse
- Department of Family and Community MedicineUniversity of California, San FranciscoSan FranciscoCA
| | - Lawrence P. Casalino
- Department of Healthcare Policy and ResearchWeill Cornell Medical CollegeNew YorkNY
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Kerrissey MJ, Clark JR, Friedberg MW, Jiang W, Fryer AK, Frean M, Shortell SM, Ramsay PP, Casalino LP, Singer SJ. Medical Group Structural Integration May Not Ensure That Care Is Integrated, From The Patient's Perspective. Health Aff (Millwood) 2018; 36:885-892. [PMID: 28461356 DOI: 10.1377/hlthaff.2016.0909] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Structural integration is increasing among medical groups, but whether these changes yield care that is more integrated remains unclear. We explored the relationships between structural integration characteristics of 144 medical groups and perceptions of integrated care among their patients. Patients' perceptions were measured by a validated national survey of 3,067 Medicare beneficiaries with multiple chronic conditions across six domains that reflect knowledge and support of, and communication with, the patient. Medical groups' structural characteristics were taken from the National Study of Physician Organizations and included practice size, specialty mix, technological capabilities, and care management processes. Patients' survey responses were most favorable for the domain of test result communication and least favorable for the domain of provider support for medication and home health management. Medical groups' characteristics were not consistently associated with patients' perceptions of integrated care. However, compared to patients of primary care groups, patients of multispecialty groups had strong favorable perceptions of medical group staff knowledge of patients' medical histories. Opportunities exist to improve patient care, but structural integration of medical groups might not be sufficient for delivering care that patients perceive as integrated.
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Affiliation(s)
- Michaela J Kerrissey
- Michaela J. Kerrissey is a doctoral student at Harvard Business School, in Boston, Massachusetts
| | - Jonathan R Clark
- Jonathan R. Clark is an assistant professor of management at the University of Texas at San Antonio
| | - Mark W Friedberg
- Mark W. Friedberg is a senior natural scientist at the RAND Corporation in Boston
| | - Wei Jiang
- Wei Jiang is a manager of biostatistics at Brigham and Women's Hospital, in Boston
| | - Ashley K Fryer
- Ashley K. Fryer is director of product strategy at Optum Analytics, in Boston
| | - Molly Frean
- Molly Frean is a doctoral student at the Wharton School, University of Pennsylvania, in Philadelphia
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior at the School of Public Health and Haas Business School, codirector of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley
| | - Patricia P Ramsay
- Patricia P. Ramsay is administrative director at the Center for Health Care Organizational and Innovation Research at the University of California, Berkeley, School of Public Health
| | - Lawrence P Casalino
- Lawrence P. Casalino is the Livingston Farrand Professor and chief of the Division of Health Policy and Economics in the Department of Healthcare Policy and Research at Weill Cornell Medical College, in New York City
| | - Sara J Singer
- Sara J. Singer is a professor of health care management and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate professor in the Department of Medicine/Mongan Institute Health Policy Center, Massachusetts General Hospital at Harvard Medical School, in Boston
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43
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Lewis VA, Fraze T, Fisher ES, Shortell SM, Colla CH. ACOs Serving High Proportions Of Racial And Ethnic Minorities Lag In Quality Performance. Health Aff (Millwood) 2018; 36:57-66. [PMID: 28069847 DOI: 10.1377/hlthaff.2016.0626] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) are intended, in part, to improve health care quality. However, little is known about how ACOs may affect disparities or how providers serving disadvantaged patients perform under Medicare ACO contracts. We analyzed racial and ethnic disparities in health care outcomes among ACOs to investigate the association between the share of an ACO's patients who are members of racial or ethnic minority groups and the ACO's performance on quality measures. Using data from Medicare and a national survey of ACOs, we found that having a higher proportion of minority patients was associated with worse scores on twenty-five of thirty-three Medicare quality performance measures, two disease composite measures, and an overall quality composite measure. However, ACOs serving a high share of minority patients were similar to other ACOs in most observable characteristics and capabilities, including provider composition, services, and clinical capabilities. Our findings suggest that ACOs with a high share of minority patients may struggle with quality performance under ACO contracts, especially during their early years of participation-maintaining or potentially exacerbating current inequities. Policy makers must consider how to refine ACO programs to encourage the participation of providers that serve minority patients and to reward performance appropriately.
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Affiliation(s)
- Valerie A Lewis
- Valerie A. Lewis is an assistant professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, in Lebanon, New Hampshire
| | - Taressa Fraze
- Taressa Fraze is a research scientist at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Elliott S Fisher
- Elliott S. Fisher is director of the Dartmouth Institute for Health Policy and Clinical Practice and the John E. Wennberg Distinguished Professor of Health Policy, Medicine, and Community and Family Medicine, Geisel School of Medicine at Dartmouth
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior, director of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley
| | - Carrie H Colla
- Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
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Peiris D, Phipps-Taylor MC, Stachowski CA, Kao LS, Shortell SM, Lewis VA, Rosenthal MB, Colla CH. ACOs Holding Commercial Contracts Are Larger And More Efficient Than Noncommercial ACOs. Health Aff (Millwood) 2018; 35:1849-1856. [PMID: 27702959 DOI: 10.1377/hlthaff.2016.0387] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Accountable care organizations (ACOs) have diverse contracting arrangements and have displayed wide variation in their performance. Using data from national surveys of 399 ACOs, we examined differences between the 228 commercial ACOs (those with commercial payer contracts) and the 171 noncommercial ACOs (those with only public contracts, such as with Medicare or Medicaid). Commercial ACOs were significantly larger and more integrated with hospitals, and had lower benchmark expenditures and higher quality scores, compared to noncommercial ACOs. Among all of the ACOs, there was low uptake of quality and efficiency activities. However, commercial ACOs reported more use of disease monitoring tools, patient satisfaction data, and quality improvement methods than did noncommercial ACOs. Few ACOs reported having high-level performance monitoring capabilities. About two-thirds of the ACOs had established processes for distributing any savings accrued, and these ACOs allocated approximately the same amount of savings to the ACOs themselves, participating member organizations, and physicians. Our findings demonstrate that ACO delivery systems remain at a nascent stage. Structural differences between commercial and noncommercial ACOs are important factors to consider as public policy efforts continue to evolve.
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Affiliation(s)
- David Peiris
- David Peiris is a Harkness Fellow at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Madeleine C Phipps-Taylor
- Madeleine C. Phipps-Taylor is a director of Allocate Software Ltd., in London, United Kingdom. At the time of this study, she was a 2014-15 Harkness Fellow at the School of Public Health at the University of California, Berkeley
| | - Courtney A Stachowski
- Courtney A. Stachowski is a research project specialist at the Dartmouth Institute for Health Policy and Clinical Practice, in Lebanon, New Hampshire
| | - Lee-Sien Kao
- Lee-Sien Kao is an associate at ideas42, in Washington, D.C. At the time of this study, she was a health policy fellow at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Stephen M Shortell
- Stephen M. Shortell is the Blue Cross of California Distinguished Professor of Health Policy and Management, a professor of organization behavior, director of the Center for Healthcare Organizational and Innovation Research, and dean emeritus, all at the School of Public Health, University of California, Berkeley
| | - Valerie A Lewis
- Valerie A. Lewis is an assistant professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
| | - Meredith B Rosenthal
- Meredith B. Rosenthal is a professor of health economics and policy in the Department of Health Policy and Management at the Harvard T. H. Chan School of Public Health
| | - Carrie H Colla
- Carrie H. Colla is an associate professor of health policy at the Dartmouth Institute for Health Policy and Clinical Practice
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Affiliation(s)
- Hugh Alderwick
- Center for Health and Community, University of California, San Francisco, CA, USA
| | | | - Adam D M Briggs
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
| | - Elliott S Fisher
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Lebanon, NH, USA
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Comfort LN, Shortell SM, Rodriguez HP, Colla CH. Medicare Accountable Care Organizations of Diverse Structures Achieve Comparable Quality and Cost Performance. Health Serv Res 2018; 53:2303-2323. [PMID: 29388199 DOI: 10.1111/1475-6773.12829] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To examine whether an empirically derived taxonomy of Accountable Care Organizations (ACOs) is associated with quality and spending performance among patients of ACOs in the Medicare Shared Savings Program (MSSP). DATA SOURCES Three waves of the National Survey of ACOs and corresponding publicly available Centers for Medicare & Medicaid Services performance data for NSACO respondents participating in the MSSP (N = 204); SK&A Office Based Physicians Database from QuintilesIMS. STUDY DESIGN We compare the performance of three ACO types (physician-led, integrated, and hybrid) for three domains: quality, spending, and likelihood of achieving savings. Sources of performance variation within and between ACO types are compared for each performance measure. PRINCIPAL FINDINGS There is greater heterogeneity within ACO types than between ACO types. There were no consistent differences in quality by ACO type, nor were there differences in likelihood of achieving savings or overall spending per-person-year. There was evidence for higher spending on physician services for physician-led ACOs. CONCLUSIONS ACOs of diverse structures perform comparably on core MSSP quality and spending measures. CMS should maintain its flexibility and continue to support participation of diverse ACOs. Future research to identify modifiable organizational factors that account for performance variation within ACO types may provide insight as to how best to improve ACO performance based on organizational structure and ownership.
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Affiliation(s)
| | | | | | - Carrie H Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH
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Cohen GR, Jones DJ, Heeringa J, Barrett K, Furukawa MF, Miller D, Mutti A, Reschovsky JD, Machta R, Shortell SM, Fraze T, Rich E. Leveraging Diverse Data Sources to Identify and Describe U.S. Health Care Delivery Systems. EGEMS (Wash DC) 2017; 5:9. [PMID: 29881758 PMCID: PMC5983023 DOI: 10.5334/egems.200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 11/17/2017] [Indexed: 11/20/2022]
Abstract
Health care delivery systems are a growing presence in the U.S., yet research is hindered by the lack of universally agreed-upon criteria to denote formal systems. A clearer understanding of how to leverage real-world data sources to empirically identify systems is a necessary first step to such policy-relevant research. We draw from our experience in the Agency for Healthcare Research and Quality's Comparative Health System Performance (CHSP) initiative to assess available data sources to identify and describe systems, including system members (for example, hospitals and physicians) and relationships among the members (for example, hospital ownership of physician groups). We highlight five national data sources that either explicitly track system membership or detail system relationships: (1) American Hospital Association annual survey of hospitals; (2) Healthcare Relational Services Databases; (3) SK&A Healthcare Databases; (4) Provider Enrollment, Chain, and Ownership System; and (5) Internal Revenue Service 990 forms. Each data source has strengths and limitations for identifying and describing systems due to their varied content, linkages across data sources, and data collection methods. In addition, although no single national data source provides a complete picture of U.S. systems and their members, the CHSP initiative will create an early model of how such data can be combined to compensate for their individual limitations. Identifying systems in a way that can be repeated over time and linked to a host of other data sources will support analysis of how different types of organizations deliver health care and, ultimately, comparison of their performance.
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Affiliation(s)
| | | | | | | | | | - Dan Miller
- Agency for Healthcare Research and Quality, US
| | | | | | | | | | - Taressa Fraze
- The Dartmouth Institute for Health Policy and Clinical Practice, US
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Pimperl AF, Rodriguez HP, Schmittdiel JA, Shortell SM. The Implementation of Performance Management Systems in U.S. Physician Organizations. Med Care Res Rev 2017; 75:562-585. [PMID: 29148329 DOI: 10.1177/1077558717696993] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Performance management systems (PMSYS) aid in improving the quality and efficiency of care, but little is known about factors that influence more robust PMSYS among physician organizations. Using a nationally representative survey of U.S. medical practices, we examined the extent to which organizational capabilities and external factors were associated with more developed PMSYS. Linear regression estimated the relative impact of these factors on PMSYS. On average, practices implemented a minority (32 points out of 100) of the PMSYS processes assessed. Practices evaluated ( p < .01) or financially incentivized by external entities ( p < .01), receiving data from health plans ( p < .01), participating in an accountable care organization ( p < .01), affiliating with an independent practice association and/or physician-hospital organization ( p < .01), and using health information technology ( p < .01) and chronic disease registries ( p < .01) to greater degrees had more robust PMSYS. PMSYS of medical practices are underdeveloped, although both external incentives and organizational capabilities may support PMSYS development.
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Fulton BD, Ivey SL, Rodriguez HP, Shortell SM. Countywide physician organization learning collaborative and changes in hospitalization rates. Am J Manag Care 2017; 23:596-603. [PMID: 29087631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES In 2011, the California Right Care Initiative implemented a countywide physician organization learning collaborative called University of Best Practices (UBP) in San Diego County for major healthcare systems and physician organizations to share best practices in managing cardiovascular and cerebrovascular risk factors. Our objective was to examine whether UBP was associated with fewer hospitalizations for heart attacks and strokes. STUDY DESIGN A quasi-experimental design was used to compare age-adjusted adult hospitalization rates before UBP initiation (2007-2010) against rates after UBP initiation (2011-2014) in San Diego County versus the rest of California. METHODS Difference-in-differences (DID) logistic regression models were estimated using hospitalization data from the California Office of Statewide Health Planning and Development for 2007 to 2014, including 372,205 and 642,455 hospitalizations for heart attacks and strokes, respectively. RESULTS In the UBP versus pre-UBP period, the odds of adults being hospitalized for a heart attack in San Diego County decreased (odds ratio [OR], 0.84), whereas the odds stayed the same for adults in the rest of California (OR, 1.00): DID ratio of OR, 0.84 (P <.001). This relative decrease was equivalent to 2735 (or 16.5%) fewer hospitalizations, totaling $61 million (2014 dollars). No robust association was found between UBP implementation and hospitalizations for strokes. CONCLUSIONS A countywide physician organization learning collaborative was associated with fewer hospitalizations for heart attacks, but not for strokes. Healthcare systems and physician organizations should consider forming collaboratives to share best practices to manage patients' cardiovascular and cerebrovascular risk factors, which may lead to fewer hospitalizations and reduced healthcare costs.
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Affiliation(s)
- Brent D Fulton
- University of California, Berkeley, 50 University Hall, MC7360, Berkeley, CA 94720. E-mail:
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Miake-Lye IM, Chuang E, Rodriguez HP, Kominski GF, Yano EM, Shortell SM. Random or predictable?: Adoption patterns of chronic care management practices in physician organizations. Implement Sci 2017; 12:106. [PMID: 28836996 PMCID: PMC5571615 DOI: 10.1186/s13012-017-0639-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 08/16/2017] [Indexed: 11/21/2022] Open
Abstract
Background Theories, models, and frameworks used by implementation science, including Diffusion of Innovations, tend to focus on the adoption of one innovation, when often organizations may be facing multiple simultaneous adoption decisions. For instance, despite evidence that care management practices (CMPs) are helpful in managing chronic illness, there is still uneven adoption by physician organizations. This exploratory paper leverages this natural variation in uptake to describe inter-organizational patterns in adoption of CMPs and to better understand how adoption choices may be related to one another. Methods We assessed a cross section of national survey data from physician organizations reporting on the use of 20 CMPs (5 each for asthma, congestive heart failure, depression, and diabetes). Item response theory was used to explore patterns in adoption, first considering all 20 CMPs together and then by subsets according to disease focus or CMP type (e.g., registries, patient reminders). Mokken scale analysis explored whether adoption choices were linked by disease focus or CMP type and whether a consistent ordering of adoption choices was present. Results The Mokken scale for all 20 CMPs demonstrated medium scalability (H = 0.43), but no consistent ordering. Scales for subsets of CMPs sharing a disease focus had medium scalability (0.4 < H < 0.5), while subsets sharing a CMP type had strong scalability (H > 0.5). Scales for CMP type consistently ranked diabetes CMPs as most adoptable and depression CMPs as least adoptable. Within disease focus scales, patient reminders were ranked as the most adoptable CMP, while clinician feedback and patient education were ranked the least adoptable. Conclusions Patterns of adoption indicate that innovation characteristics may influence adoption. CMP dissemination efforts may be strengthened by encouraging traditionally non-adopting organizations to focus on more adoptable practices first and then describing a pathway for the adoption of subsequent CMPs. Clarifying why certain CMPs are “less adoptable” may also provide insights into how to overcome CMP adoption constraints. Electronic supplementary material The online version of this article (doi:10.1186/s13012-017-0639-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isomi M Miake-Lye
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA. .,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA.
| | - Emmeline Chuang
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Hector P Rodriguez
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
| | - Gerald F Kominski
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA
| | - Elizabeth M Yano
- Department of Health Policy and Management, UCLA Jonathan and Karin Fielding School of Public Health, 640 Charles E. Young Drive South, Los Angeles, CA, 90024, USA.,Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA
| | - Stephen M Shortell
- Department of Health Policy and Management, UC-Berkeley School of Public Health, 50 University Hall, Berkeley, CA, 94720, USA
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