A Medicaid-Funded Statewide Diabetes Quality Improvement Collaborative: Ohio 2020‒2022

We used a collective impact model to form a statewide diabetes quality improvement collaborative to improve diabetes outcomes and advance diabetes health equity. Between 2020 and 2022, in collaboration with the Ohio Department of Medicaid, Medicaid Managed Care Plans, and Ohio's seven medical schools, we recruited 20 primary care practices across the state. The percentage of patients with hemoglobin A1c greater than 9% improved from 25% to 20% over two years. Applying our model more broadly could accelerate improvement in diabetes outcomes. (Am J Public Health. 2023;113(12):1254-1257. https://doi.org/10.2105/AJPH.2023.307410).

A Medicaid Statewide Hypertension Quality Improvement Project: Initial Results

Background Hypertension control is critical to reducing cardiovascular disease, challenging to achieve, and exacerbated by socioeconomic inequities. Few states have established statewide quality improvement (QI) infrastructures to improve blood pressure (BP) control across economically disadvantaged populations. In this study, we aimed to improve BP control by 15% for all Medicaid recipients and by 20% for non-Hispanic Black participants. Methodology This QI study used repeated cross-sections of electronic health record data and, for Medicaid enrollees, linked Medicaid claims data for 17,672 adults with hypertension seen at one of eight high-volume Medicaid primary care practices in Ohio from 2017 to 2019. Evidence-based strategies included (1) accurate BP measurement; (2) timely follow-up; (3) outreach; (4) a standardized treatment algorithm; and (5) effective communication. Payers focused on a 90-day supply (vs. 30-day) of BP medications, home BP monitor access, and outreach. Implementation efforts included an in-person kick-off followed by monthly QI coaching and monthly webinars. Weighted generalized estimating equations were used to estimate the baseline, one-year, and two-year implementation change in the proportion of visits with BP control (<140/90 mm Hg) stratified by race/ethnicity. Results For all practices, the percentage of participants with controlled BP increased from 52% in 2017 to 60% in 2019. Among non-Hispanic Whites, the odds of achieving BP control in year one and year two were 1.24 times (95% confidence interval: 1.14, 1.34) and 1.50 times (1.38, 1.63) higher relative to baseline, respectively. Among non-Hispanic Blacks, the odds for years one and two were 1.18 times (1.10, 1.27) and 1.34 times (1.24, 1.45) higher relative to baseline, respectively. Conclusions A hypertension QI project as part of establishing a statewide QI infrastructure improved BP control in practices with a high volume of disadvantaged patients. Future efforts should investigate ways to reduce inequities in BP control and further explore factors associated with greater BP improvements and sustainability.

Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach

BACKGROUND

Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities.

OBJECTIVE

To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems.

DESIGN

Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017).

PARTICIPANTS

Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative.

INTERVENTIONS

Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching).

MAIN MEASURES

We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics.

KEY RESULTS

BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3).

CONCLUSIONS

Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

Adjusting to life when assisted conception fails

According to our basic (psychosomatic) tenet, every somatic problem has its emotional side; therefore, medical treatment and counselling are not separate but are interlinked and equally important. First interviews and interviews after failed assisted reproductive technology (ART) are held together in four person settings; the couple with two counsellors. The sessions last for approximately 1 h. The aim is to help patients escape the agonizing and distressing state in which they are kept by their foci (psychogenic aspects causing distress). Stress and iatrogenic factors are discussed and when patients are able to re-experience their suffering, many possible psychological effects on infertility and/or treatment failure are explored. If the patients consciously perceive these mechanisms of action, they will turn to their basic emotional needs and perspectives; approximately 30% of them will conceive later while approximately 20% opt for adoption. However, half of the patients take no positive action, neither giving up nor continuing with activities for a child. Nor do they seek counselling. The analysis of many of their reports argues in favour of an adaptive model for coping with reproductive failure.

Psychosomatic aspects of galactorrhea

We interviewed 33 women with non-puerperal galactorrhea, 5 (15%) of whom had HPRL levels greater than 18 ng/ml and 24 controls, namely women with benign breast lesions. We used a semi-structured interview covering the duration of symptoms, preceding life events and the effect on the relationship of the couple. We also used the Beck depression inventory, the Strauss and Appelt body image questionnaire and an 8 item Visual Analogue Scale (VAS). Galactorrheic women were more depressive (P less than 0.1), had more prior life events (P less than 0.001), longer duration of symptoms (P less than 0.01), and less fear of their disease (P less than 0.05) than did controls. Both groups had similar results with the body image questionnaire. Within the study group, results were independent of prolactin (HPRL) levels or amenorrhea.

[Integration of psychological management strategies in the treatment course of breast carcinoma]

The integration of psychological counselling programmes into the treatment procedures of breast cancer has to overcome specific methodological and contextual difficulties. We present a counselling strategy for breast cancer patients which aims at a reduction of short-term sequelae of the crisis of cancer diagnosis and stress of therapy. Its main features, summarized as follows are based on the relevant literature and the results of a pilot study in our department. Counselling is offered and made available to all patients, since both self- and professional referral lead to a selection bias. Psychological counselling is considered as integral part of the entire diagnostic and therapeutic process. The psychologist acts as a continuous supportive partner at all relevant treatment stages, and is introduced to the patient at the outset of the therapy and is always available as familiar contact person for discussion of all problems. Intensity and structure of counselling closely follow the different stages of somatic treatment. Technically, elements of crisis intervention and Progressive Muscular Relaxation (PME, according to Jacobson) are applied. Aspects of patient/doctor relationship and interdisciplinary cooperation between physicians and psychologists are discussed.

[Side effects of adjuvant therapies of breast cancer: their significance for the patient]

In a retrospective survey we interviewed 53 patients with respect to side effects of adjuvant therapy for breast cancer. All of them had undergone modified mastectomy and were randomly assigned to either chemotherapy, irradiation or a combination of both. Standardized questionnaires concerning the side effects and semi-structured, focusing counseling talks were the methods used in questioning the patients. Patients named significantly more side effects of severe and extreme intensity with chemotherapy, and especially in the group given combination therapy, where chemo- and radiotherapy could be directly compared by the patient. The experience was particularly threatening when several side effects occurred simultaneously. Different psychological aspects and visualisation of systemic and local side effects are discussed with respect to the patient's ability to cope with adjuvant therapy. Consequences for routine care are: continuous explanatory talks about side effects throughout the whole process, muscle relaxation and interdisciplinary cooperation.