Evidence on bringing specialised care to the primary level-effects on the Quadruple Aim and cost-effectiveness: a systematic review

BACKGROUND

To achieve the Quadruple Aim of improving population health, enhancing the patient experience of care, reducing costs and improving professional satisfaction requires reorganisation of health care. One way to accomplish this aim is by integrating healthcare services on different levels. This systematic review aims to determine whether it is cost-effective to bring a hospital specialist into primary care from the perspectives of commissioners, patients and professionals.

METHODS

The review follows the PRISMA guidelines. We searched PubMed, Scopus and EBSCO (CINAHL and Academic Search Ultimate) for the period of 1992-2022. In total, 4254 articles were found, and 21 original articles that reported on both quality and costs, were included. The JBI and ROBINS-I tools were used for quality appraisal. In data synthesis, vote counting and effect direction plots were used together with a sign test. The strength of evidence was evaluated with the GRADE.

RESULTS

Cost-effectiveness was only measured in two studies, and it remains unclear. Costs and cost drivers for commissioners were lower in the intervention in 52% of the studies; this proportion rose to 67% of the studies when cost for patients was also considered, while health outcomes, patient experience and professional satisfaction mostly improved but at least remained the same. Costs for the patient, where measured, were mainly lower in the intervention group. Professional satisfaction was reported in 48% of the studies; in 80% it was higher in the intervention group. In 24% of the studies, higher monetary costs were reported for commissioners, whereas the clinical outcomes, patient experience and costs for the patient mainly improved.

CONCLUSIONS

The cost-effectiveness of the hospital specialist in primary care model remains inconclusive. Only a few studies have comprehensively calculated costs, evaluating cost drivers. However, it seems that when the service is well organised and the population is large enough, the concept can be profitable for the commissioner also. From the patient's perspective, the model is superior and could even promote equity through improved access. Professional satisfaction is mostly higher compared to the traditional model. The certainty of evidence is very low for cost and low for quality.

TRIAL REGISTRATION

PROSPERO CRD42022325232, 12.4.2022.

Measuring Interprofessional Collaboration's Impact on Healthcare Services Using the Quadruple Aim Framework: A Protocol Paper

Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to a tangible effect on healthcare outcomes. Without return on investment (ROI) evidence, healthcare leaders cannot justifiably throw their weight behind IPC, and the institutional push for healthcare manpower reforms crucial for facilitating IPC will remain variable and fragmentary. The lack of proof for the ROI of IPC is likely due to a lack of a unifying conceptual framework and the over-reliance on the single-method study design. To address the gaps, this paper describes a protocol which uses as a framework the Quadruple Aim which examines the ROI of IPC using four dimensions: patient outcomes, patient experience, provider well-being, and cost of care. A multimethod approach is proposed whereby patient outcomes are measured using quantitative methods, and patient experience and provider well-being are assessed using qualitative methods. Healthcare costs will be calculated using the time-driven activity-based costing methodology. The study is set in a Singapore-based national and regional center that takes care of patients with neurological issues.

Improving the colorectal cancer care pathway via e-health: a qualitative study among Dutch healthcare providers and managers

PURPOSE

This study aims to identify improvement opportunities within the colorectal cancer (CRC) care pathway using e-health and to examine how these opportunities would contribute to the Quadruple Aim.

METHODS

In total, 17 semi-structured interviews were held (i.e., nine healthcare providers and eight managers involved in Dutch CRC care). The Quadruple Aim was used as a conceptual framework to gather and systematically structure the data. A directed content analysis approach was employed to code and analyze the data.

RESULTS

Interviewees believe the available e-health technology could be better exploited in CRC care. Twelve different improvement opportunities were identified to enhance the CRC care pathway. Some opportunities could be applied in one specific phase of the pathway (e.g., digital applications to support patients in the prehabilitation program to enhance the program's effects). Others could be deployed in multiple phases or extended outside the hospital care setting (e.g., digital consultation hours to increase care accessibility). Some opportunities could be easily implemented (e.g., digital communication to facilitate treatment preparation), whereas others require structural, systemic changes (e.g., increasing efficiency in patient data exchanges among healthcare professionals).

CONCLUSION

This study provides insights into how e-health could add value to CRC care and contribute to the Quadruple Aim. It shows that e-health has the potential to contribute to the challenges in cancer care. To take the next step forward, the perspectives of other stakeholders must be examined, the identified opportunities should be prioritized, and the requirements for successful implementation should be mapped out.

Towards the Quadruple Aim in permanent supportive housing: A mixed methods study of workplace mental health among service providers

The Quadruple Aim is a health policy framework with the objective of concurrently improving population health, enhancing the service experience, reducing costs and improving the work-life of service providers. Permanent supportive housing (PSH) is a best practice approach for stably housing people experiencing homelessness who have diverse support needs. Despite the intervention's strong evidence base, little is known about the work-life of PSH providers. This study explored the mental health and work challenges experienced by PSH providers in Canada. Using an explanatory sequential, equally weighted, mixed methods design, 130 PSH providers were surveyed, followed by semi-structured interviews with 18 providers. Quantitative findings showed that 23.1% of PSH providers had high psychological distress. Participants who were younger, spent all or almost all of their time in direct contact with service users and had less social support from coworkers were significantly more likely to have high psychological distress. Three themes were identified from the qualitative analysis that showed how PSH providers experience psychological distress from work-related challenges: (a) Sisyphean Endeavours: 'You Do What You Can', (b) Occupationally Unsupported: 'Everyone Is Stuck in Their Zone' and (c) Wear and Tear of 'Continuous Exposure to Crisis and Chaos'. The themes interacted with systemic (Sisyphean Endeavours) and organisational issues (Occupationally Unsupported), intensifying the emotional burden of day-to-day work, which involved frequent crises and uncertainty (Wear and Tear of 'Continuous Exposure to Crisis and Chaos'). The findings underscore how these challenges threaten providers' wellness at work and have implications for the care provided to service users. Accordingly, the Quadruple Aim is a potentially useful and applicable framework for measuring the performance of PSH programs, which warrants further consideration in research and policy.

Leading from the Middle: Practical Innovation in Public Mental Health

Leaders in public mental health are responsible for ensuring the care environment is conducive to provider wellbeing, and ultimately patient care. Given the effects of stress and burnout, healthcare organizations must explore interventions to support their employees. The Leadership + Innovation Lab is a pilot project focused on enhancing leadership skills, innovation capacity, and peer connections among clinical managers. Participants executed individual or group projects to improve the care environment and co-created a peer consultation program. They reported increased connection with peers, innovation and leadership skills, and capacity to facilitate a better experience for their provider staff as a result of the program. This model can be used in other settings to help achieve the goals of the Quadruple Aim and improve communication.

Technological Change and Frontline Care Delivery Work: Toward the Quadruple Aim

The COVID-19 pandemic stressed the health care sector's longstanding pain points, including the poor quality of frontline work and the staffing challenges that result from it. This has renewed interest in technology-centered approaches to achieving not only the "Triple Aim" of reducing costs while raising access and quality but also the "Quadruple Aim" of doing so without further squeezing wages and abrading job quality for frontline workers. How can we leverage technology toward the achievement of the Quadruple Aim? I view this as a "grand challenge" for health care managers and policymakers. Those looking for guidance will find that most analyses of the workforce impact of technological change consider broad classes of technology such as computers or robots outside of any particular industry context. Further, they typically predict changes in work or labor market outcomes will come about at some ill-defined point in the medium to long run. This decontextualization and detemporization proves markedly problematic in the health care sector: the nonmarket, institutional factors driving technology adoption and implementation loom especially large in frontline care delivery, and managers and policymakers understandably must consider a well-defined, near-term, i.e., 5-10-year, time horizon. This study is predicated on interviews with hospital and home health agency administrators, union representatives, health care information technology (IT) experts and consultants, and technology developers. I detail the near-term drivers and anticipated workforce impact of technological changes in frontline care delivery. With my emergent prescriptions for managers and policymakers, I hope to guide sectoral actors in using technology to address the "grand challenge" inherent to achieving the Quadruple Aim.

Interdisciplinary Care Networks in Rehabilitation Care for Patients with Chronic Musculoskeletal Pain: A Systematic Review

This systematic review aims to identify what rehabilitation care networks, within primary care or between primary and other health care settings, have been described for patients with chronic musculoskeletal pain, and what their impact is on the Quadruple Aim outcomes (health; health care costs; quality of care experienced by patients; work satisfaction for health care professionals). Studies published between 1 January 1994 and 11 April 2019 were identified in PubMed, CINAHL, Web of Science, and PsycInfo. Forty-nine articles represented 34 interventions: 21 within primary care; 6 between primary and secondary/tertiary care; 1 in primary care and between primary and secondary/tertiary care; 2 between primary and social care; 2 between primary, secondary/tertiary, and social care; and 2 between primary and community care. Results on impact were presented in 19 randomized trials, 12 non-randomized studies, and seven qualitative studies. In conclusion, there is a wide variety of content, collaboration, and evaluation methods of interventions. It seems that patient-centered interdisciplinary interventions are more effective than usual care. Further initiatives should be performed for interdisciplinary interventions within and across health care settings and evaluated with mixed methods on all Quadruple Aim outcomes.

Enhancing healthcare efficiency to achieve the Quadruple Aim: an exploratory study

Objective

Healthcare is battling a conflict between the Quadruple Aims—reducing costs; improving population health, patient experience, and team well-being—and productivity. This quasi-experimental pilot study tested a 2 week intervention aimed to address the Quadruple Aims while improving productivity. Participants were 25 employees and their patients in a primary care clinic. One provider and their team implemented an efficiency-focused intervention that modified work roles and processes focused on utilizing all team members’ skills as allowable by applicable licensure restrictions. The five remaining providers and their teams comprised the reference group, who continued patient care as usual. Study outcomes were measured via provider/staff and patient surveys and administrative data.

Results

In total, 46 team surveys and 156 patient surveys were collected. Clinic output data were retrieved for 467 visits. Compared to the reference team, the intervention team performed better in all Quadruple Aims and productivity measures. The intervention group offered 48% more patient slots than the average reference team. These preliminary results support the feasibility of introducing substantial process changes that show promising improvement in both the Quadruple Aims and productivity. A larger-scale study over a longer time period is needed to confirm findings and examine feasibility and cost-effectiveness.

Achieving the Quadruple Aim Through Bidirectional Care

This chapter discusses the notion of 'bidirectional health literacy' between the patient/care partner and the care team, and its impact on the quadruple aim: the care experience, population health, engagement, and the cost of care. It provides a brief historical perspective of the quadruple aim along with its relationships to value and health literacy. It overviews the responsibilities of health care organizations and highlights best practices, such as bidirectional care opportunities in patient-centered medical homes, with a focus on improving provider and care team communication. The chapter's aim is to provide a new bidirectional perspective on health literacy. It illuminates for readers that the focus of health literacy should not just be about patients' understanding of and engagement in their own health and health care, but instead, a partnership where care teams become equally 'literate' about the patient/care partner, by learning what they value, the contextual and social determinants that impact their ability to engage in self-care, and by demonstrating cultural humility in all of their care efforts. Various models that support bidirectional literacy and care are provided.

How Health Literacy Develops the 'Four Aims' of Better Health Care

The chapter's audience and purpose are twofold. First, the chapter introduces the 'Quadruple Aim' to policy makers and provides a general overview of health literacy strategies and tools to meet the Quadruple Aim to enhance care delivery while reducing costs. Second, the chapter identifies gaps in health literacy related research and encourages a research agenda to further the evidence base of health literacy to reduce cost, enhance quality, increase access, improve satisfaction, and achieve health equity.

Ten Ways Artificial Intelligence Will Transform Primary Care

Artificial intelligence (AI) is poised as a transformational force in healthcare. This paper presents a current environmental scan, through the eyes of primary care physicians, of the top ten ways AI will impact primary care and its key stakeholders. We discuss ten distinct problem spaces and the most promising AI innovations in each, estimating potential market sizes and the Quadruple Aims that are most likely to be affected. Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale. We propose how these AI-powered innovations must augment, not subvert, the patient-physician relationship for physicians and patients to accept them. AI implemented poorly risks pushing humanity to the margins; done wisely, AI can free up physicians' cognitive and emotional space for patients, and shift the focus away from transactional tasks to personalized care. The challenge will be for humans to have the wisdom and willingness to discern AI's optimal role in twenty-first century healthcare, and to determine when it strengthens and when it undermines human healing. Ongoing research will determine the impact of AI technologies in achieving better care, better health, lower costs, and improved well-being of the workforce.

Quality improvement and models of behavioral healthcare integration: Position paper #2 from the International Society of Psychiatric-Mental Health Nurses

This is the second article in a series written to present and address the position of the International Society of Psychiatric-Mental Health Nurses (ISPN) related to the notion of behavioral healthcare integration and the role of nurses in the 21st century. The first article addressed assumptions, definitions and roles related to the integration of behavioral healthcare. The purpose of this article is to focus on Integrated Care within the context of recent initiatives that endeavor to improve quality, safety and reduce costs in the US healthcare system also known as the "Triple Aim" (or more recently, the Quadruple Aim). This paper specifically focuses on the role of nurses and nursing practice by: (a) connecting the concept of integrated behavioral healthcare to quality improvement (QI) and the Quadruple Aim, and (b) highlighting examples of models of integration currently in use. Discussion of models of integration compares ways various models reinforce and actualize integration of behavioral health within primary care, in various special populations across the continuum of care, and in both inpatient and community settings. This paper also stresses innovative training programs offering nurses the skills for learning behavioral health integration through online modules and participation in Interprofessional Education (IPE) activities often through simulation approaches. This 2nd manuscript is consistent with the ISPN 2016 Position Paper and reinforces the necessity for all nurses to be educated on both the Quadruple Aim and behavioral health integration to improve patient care and subsequent care outcomes.

Colorectal Cancer: Applying the Value Transformation Framework to increase the percent of patients receiving screening in Federally Qualified Health Centers

Background

Colorectal cancer is the second leading cause of cancer death in the U.S. and third-most common cancer in both men and women. Colorectal cancer screening (CRCS) rates remain low, particularly among vulnerable patients receiving care at federally qualified health centers. Through its Value Transformation Framework, the National Association of Community Health Centers provides a systematic approach to improving CRCS by transforming health center infrastructure, care delivery, and people systems—to improve health outcomes, patient and staff experiences, and lower costs (Quadruple Aim).

Methods

We combined the Value Transformation Framework, evidence-based CRCS interventions, and the Learning Community Model to drive system improvements and implement evidence-based practices. Multi-disciplinary teams at 8 health centers in Georgia and Iowa participated for 1-year with Primary Care Association support.

Results

Pre−/post- 1-year-intervention data showed, within health centers, raw percentage of eligible patients screened for CRC increased from 33.2% (13.5%–61.7%) in January 2017 to 46.5% (14.2%–81.5%) in December 2017, with an overall 13.3 percentage point average increase. This translates into an average increase of 3.3 (95% CI: 1.7, 5.0) eligible patients screened per month per health center over the year or 317 additional patients meeting CRCS guidelines. Specific interventions associated with higher CRCS rates included standing orders, sharing performance data, and electronic health record alerts.

Conclusion

Findings support a three-pronged approach for improving CRCS: The Value Transformation Framework's evidence-based recommendations, with actionable CRC interventions, offered in a learning community. These results guide methodological approaches to improving CRCS in health centers through a multi-level, multi-modality quality improvement and transformation approach.

Systematic Review of Community Paramedicine and EMS Mobile Integrated Health Care Interventions in the United States

Emergency medical services (EMS) in the United States are frequently used for nonurgent medical needs. Use of 911 and the emergency department (ED) for primary care-treatable conditions is expensive, inefficient, and undesirable for patients and providers. The objective is to describe the outcomes from community paramedicine (CP) and mobile integrated health care (MIH) interventions related to the Quadruple Aim. Three electronic databases were searched for peer-review literature on CP-MIH interventions in the United States. Eight articles reporting data from 7 interventions were included. Four studies reported high levels of patient satisfaction, and only 3 measured health outcomes. No study reported provider satisfaction measures. Reducing ED and inpatient utilization were the most common study outcomes, and programs generally were successful at reducing utilization. With reduced utilization, costs should be reduced; however, most studies did not quantify savings. Future studies should conduct economic analyses that not only compare the intervention to traditional EMS services, but also measure potential cost savings to the EMS agencies running the intervention. Most cost savings from reduced utilization will be to insurance companies and patients, but more efficient use of EMS agencies' resources could lead to cost savings that could offset intervention implementation costs. The other 3 aims (health, patient satisfaction, and provider satisfaction) were reported inconsistently in these studies and need to be addressed further. Given the small number of heterogeneous studies reviewed, the potential for CP-MIH interventions to comprehensively address the Quadruple Aim is still unclear, and more research on these programs is needed.

Primary Care 2.0: Design of a Transformational Team-Based Practice Model to Meet the Quadruple Aim

A new transformational model of primary care is needed to address patient care complexity and provider burnout. An 18-month design effort (2015-2016) included the following: (1) Needs Finding, (2) Integrated Facility Design, (3) Design Process Assessment, and (4) Development of Evaluation. Initial outcome metrics were assessed. The design team successfully applied Integrated Facility Design to primary care transformation design; qualitative survey results suggest that design consensus was facilitated by team-building activities. Initial implementation of Quadruple Aim-related outcome metrics showed positive trends. Redesign processes may benefit from emphasis on team building to facilitate consensus and increased patient involvement to incorporate patient voices successfully.

Gaming science innovations to integrate health systems science into medical education and practice

Health systems science (HSS) is an emerging discipline addressing multiple, complex, interdependent variables that affect providers' abilities to deliver patient care and influence population health. New perspectives and innovations are required as physician leaders and medical educators strive to accelerate changes in medical education and practice to meet the needs of evolving populations and systems. The purpose of this paper is to introduce gaming science as a lens to magnify HSS integration opportunities in the scope of medical education and practice. Evidence supports gaming science innovations as effective teaching and learning tools to promote learner engagement in scientific and systems thinking for decision making in complex scenarios. Valuable insights and lessons gained through the history of war games have resulted in strategic thinking to minimize risk and save lives. In health care, where decisions can affect patient and population outcomes, gaming science innovations have the potential to provide safe learning environments to practice crucial decision-making skills. Research of gaming science limitations, gaps, and strategies to maximize innovations to further advance HSS in medical education and practice is required. Gaming science holds promise to equip health care teams with HSS knowledge and skills required for transformative practice. The ultimate goals are to empower providers to work in complex systems to improve patient and population health outcomes and experiences, and to reduce costs and improve care team well-being.