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Connell SS, Chang RN, Royse KE, Benson NJ, Tran LP, Fasig BH, Paxton LW, Balough BJ. Seven-Year Revision Rates for Cochlear Implants in Pediatric and Adult Populations of an Integrated Healthcare System. Otol Neurotol 2024; 45:529-535. [PMID: 38693093 DOI: 10.1097/mao.0000000000004191] [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: 05/03/2024]
Abstract
OBJECTIVE We assessed three cochlear implant (CI) suppliers: Advanced Bionics, Cochlear Limited, and MED-EL, for implant revision requiring reoperation after CI placement. STUDY DESIGN Retrospective cohort study of integrated-health-system database between 2010 and 2021. Separate models were created for pediatric (age <18) and adult (age ≥18) cohorts. PATIENTS Pediatric (age <18) and adult (age ≥18) patients undergoing cochlear implantation within our integrated healthcare system. MAIN OUTCOME MEASURE Revision after CI placement. Cox proportional hazard regression was used to evaluate revision risk and adjust for confounding factors. Hazard ratios (HRs) and 95% confidence intervals (CIs) are presented. RESULTS A total of 2,347 patients underwent a primary CI placement, and Cochlear Limited was most implanted (51.5%), followed by Advanced Bionics (35.2%) and MED-EL (13.3%). In the pediatric cohort, the 7-year crude revision rate was 10.9% for Advanced Bionics and 4.8% for Cochlear Limited, whereas MED-EL had insufficient cases. In adults, the rates were 9.1%, 4.5%, and 3.3% for Advanced Bionics, MED-EL, and Cochlear Limited, respectively. After 2 years of postoperative follow-up, Advanced Bionics had a significantly higher revision risk (HR = 8.25, 95% CI = 2.91-23.46); MED-EL had no difference (HR = 2.07, 95% CI = 0.46-9.25). CONCLUSION We found an increased revision risk after 2 years of follow-up for adults with Advanced Bionics CI devices. Although we found no statistical difference between manufacturers in the pediatric cohort, after 2 years of follow-up, there were increasing trends in the revision probability for Advanced Bionics. Further research may determine whether patients are better suited for some CI devices.
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Affiliation(s)
- Sarah S Connell
- Otolaryngology H&N Surgery, Kaiser Permanente, Woodland Hills, California
| | - Richard N Chang
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Kathryn E Royse
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | | | - LenhAnh P Tran
- Otolaryngology H&N Surgery, Kaiser Permanente, Honolulu, Hawaii
| | - Brian H Fasig
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Liz W Paxton
- Medical Device Surveillance & Assessment, Kaiser Permanente, San Diego, California
| | - Ben J Balough
- Department of Head and Neck Surgery, Kaiser Permanente, Sacramento, California
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Bsteh G, Macher S, Krajnc N, Marik W, Michl M, Müller N, Zaic S, Harreiter J, Novak K, Wöber C, Pemp B. An interdisciplinary integrated specialized one-stop outpatient clinic for idiopathic intracranial hypertension - an assessment of sick leave, presenteeism, and health care utilization. J Headache Pain 2024; 25:73. [PMID: 38714920 PMCID: PMC11075215 DOI: 10.1186/s10194-024-01780-9] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/23/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Management of idiopathic intracranial hypertension (IIH) is complex requiring contributions from multiple specialized disciplines. In practice, this creates considerable organizational and communicational challenges. To meet those challenges, we established an interdisciplinary integrated outpatient clinic for IIH with a central coordination and a one-stop- concept. Here, we aimed to evaluate effects of this concept on sick leave, presenteeism, and health care utilization. METHODS In a retrospective cohort study, we compared the one-stop era with integrated care (IC, 1-JUL-2021 to 31-DEC-2022) to a reference group receiving standard care (SC, 1-JUL-2018 to 31-DEC-2019) regarding economic outcome parameters assessed over 6 months. Multivariate binary logistic regression models were used to adjust for confounders. RESULTS Baseline characteristics of the IC group (n = 85) and SC group (n = 81) were comparable (female: 90.6% vs. 90.1%; mean age: 33.6 vs. 32.8 years, educational level: ≥9 years of education 60.0% vs. 59.3%; located in Vienna 75.3% vs. 76.5%). Compared to SC, the IC group showed significantly fewer days with sick leave or presenteeism (-5 days/month), fewer unscheduled contacts for IIH-specific problems (-2.3/month), and fewer physician or hospital contacts in general (-4.1 contacts/month). Subgroup analyses of patients with migration background and language barrier consistently indicated stronger effects of the IC concept in these groups. CONCLUSIONS Interdisciplinary integrated management significantly improves the burden of IIH in terms of sick leave, presenteeism and healthcare consultations - particularly in socioeconomically underprivileged patient groups.
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Affiliation(s)
- Gabriel Bsteh
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria.
| | - Stefan Macher
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Nik Krajnc
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Marik
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neuroradiology, Medical University of Vienna, Vienna, Austria
| | - Martin Michl
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Nina Müller
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Sina Zaic
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Jürgen Harreiter
- Division of Endocrinology, Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus Novak
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Christian Wöber
- Department of Neurology, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Comprehensive Center for Clinical Neurosciences & Mental Health, Medical University of Vienna, Vienna, Austria
| | - Berthold Pemp
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
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Ambrosy AP, Parikh RV, Sung SH, Narayanan A, Masson R, Lam PQ, Kheder K, Iwahashi A, Hardwick AB, Fitzpatrick JK, Avula HR, Selby VN, Shen X, Sanghera N, Cristino J, Go AS. A Natural Language Processing-Based Approach for Identifying Hospitalizations for Worsening Heart Failure Within an Integrated Health Care Delivery System. JAMA Netw Open 2021; 4:e2135152. [PMID: 34807259 PMCID: PMC8609413 DOI: 10.1001/jamanetworkopen.2021.35152] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE The current understanding of epidemiological mechanisms and temporal trends in hospitalizations for worsening heart failure (WHF) is based on claims and national reporting databases. However, these data sources are inherently limited by the accuracy and completeness of diagnostic coding and/or voluntary reporting. OBJECTIVE To assess the overall burden of and temporal trends in the rate of hospitalizations for WHF. DESIGN, SETTING, AND PARTICIPANTS This cohort study, performed from January 1, 2010, to December 31, 2019, used electronic health record (EHR) data from a large integrated health care delivery system. EXPOSURES Calendar year trends. MAIN OUTCOMES AND MEASURES Hospitalizations for WHF (ie, excluding observation stays) were defined as 1 symptom or more, 2 objective findings or more including 1 sign or more, and 2 doses or more of intravenous loop diuretics and/or new hemodialysis or continuous kidney replacement therapy. Symptoms and signs were identified using natural language processing (NLP) algorithms applied to EHR data. RESULTS The study population was composed of 118 002 eligible patients experiencing 287 992 unique hospitalizations (mean [SD] age, 75.6 [13.1] years; 147 203 [51.1%] male; 1655 [0.6%] American Indian or Alaska Native, 28 451 [9.9%] Asian or Pacific Islander, 34 903 [12.1%] Black, 23 452 [8.1%] multiracial, 175 840 [61.1%] White, and 23 691 [8.2%] unknown), including 65 357 with a principal discharge diagnosis and 222 635 with a secondary discharge diagnosis of HF. The study population included 59 868 patients (20.8%) with HF with a reduced ejection fraction (HFrEF) (<40%), 33 361 (11.6%) with HF with a midrange EF (HFmrEF) (40%-49%), 142 347 (49.4%) with HF with a preserved EF (HFpEF) (≥50%), and 52 416 (18.2%) with unknown EF. A total of 58 042 admissions (88.8%) with a primary discharge diagnosis of HF and 62 764 admissions (28.2%) with a secondary discharge diagnosis of HF met the prespecified diagnostic criteria for WHF. Overall, hospitalizations for WHF identified on NLP-based algorithms increased from 5.2 to 7.6 per 100 hospitalizations per year during the study period. Subgroup analyses found an increase in hospitalizations for WHF based on NLP from 1.5 to 1.9 per 100 hospitalizations for HFrEF, from 0.6 to 1.0 per 100 hospitalizations for HFmrEF, and from 2.6 to 3.9 per 100 hospitalizations for HFpEF. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that the burden of hospitalizations for WHF may be more than double that previously estimated using only principal discharge diagnosis. There has been a gradual increase in the rate of hospitalizations for WHF with a more noticeable increase observed for HFpEF.
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Affiliation(s)
- Andrew P. Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Rishi V. Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Sue Hee Sung
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Anand Narayanan
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Rajeev Masson
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Phuong-Quang Lam
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Kevin Kheder
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Alan Iwahashi
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Alexander B. Hardwick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Jesse K. Fitzpatrick
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Harshith R. Avula
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Van N. Selby
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Joaquim Cristino
- Department of Cardiology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, California
| | - Alan S. Go
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
- Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco
- Department of Medicine, Stanford University, Palo Alto, California
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Dunn C, Gately L, Gibbs P. Drinking from the firehose - A clinician's perspective on the challenges of delivering biomarker-driven care in routine practice. Eur J Cancer 2021; 157:301-305. [PMID: 34555649 DOI: 10.1016/j.ejca.2021.08.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 08/23/2021] [Accepted: 08/29/2021] [Indexed: 12/27/2022]
Abstract
Countless biomarkers continue to be identified and analysed in the modern era of omics focused research, with innumerable articles purporting clinical utility and bolstering optimism for truly personalised cancer care. While many commentaries have expounded on the complexities of biomarker development, validation and reporting, the monumental challenge of integrating this research into clinical practice has to date received little attention. The challenges are multitude; variable and sometimes contradictory findings across studies for individual biomarkers, a rapidly evolving landscape with new biomarkers continually being presented and tendency to examine each biomarker in isolation. Here, using examples from colorectal cancer, we explore the difficulties for the practicing clinician in interpreting and integrating novel biomarkers. Here, we present the '4Cs' to interrogate the biomarker literature, including analysis of the credibility, consistency, completeness and context of the biomarker research, and suggest a framework to frame the literature moving forward.
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Affiliation(s)
- Catherine Dunn
- Personalised Medicine Division, Walter and Eliza Hall, Melbourne, VIC, Australia.
| | - Lucy Gately
- Personalised Medicine Division, Walter and Eliza Hall, Melbourne, VIC, Australia
| | - Peter Gibbs
- Personalised Medicine Division, Walter and Eliza Hall, Melbourne, VIC, Australia; University of Melbourne, Department of Medicine, Melbourne, VIC, Australia
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Marafino BJ, Escobar GJ, Baiocchi MT, Liu VX, Plimier CC, Schuler A. Evaluation of an intervention targeted with predictive analytics to prevent readmissions in an integrated health system: observational study. BMJ 2021; 374:n1747. [PMID: 34380667 PMCID: PMC8356037 DOI: 10.1136/bmj.n1747] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To determine the associations between a care coordination intervention (the Transitions Program) targeted to patients after hospital discharge and 30 day readmission and mortality in a large, integrated healthcare system. DESIGN Observational study. SETTING 21 hospitals operated by Kaiser Permanente Northern California. PARTICIPANTS 1 539 285 eligible index hospital admissions corresponding to 739 040 unique patients from June 2010 to December 2018. 411 507 patients were discharged post-implementation of the Transitions Program; 80 424 (19.5%) of these patients were at medium or high predicted risk and were assigned to receive the intervention after discharge. INTERVENTION Patients admitted to hospital were automatically assigned to be followed by the Transitions Program in the 30 days post-discharge if their predicted risk of 30 day readmission or mortality was greater than 25% on the basis of electronic health record data. MAIN OUTCOME MEASURES Non-elective hospital readmissions and all cause mortality in the 30 days after hospital discharge. RESULTS Difference-in-differences estimates indicated that the intervention was associated with significantly reduced odds of 30 day non-elective readmission (adjusted odds ratio 0.91, 95% confidence interval 0.89 to 0.93; absolute risk reduction 95% confidence interval -2.5%, -3.1% to -2.0%) but not with the odds of 30 day post-discharge mortality (1.00, 0.95 to 1.04). Based on the regression discontinuity estimate, the association with readmission was of similar magnitude (absolute risk reduction -2.7%, -3.2% to -2.2%) among patients at medium risk near the risk threshold used for enrollment. However, the regression discontinuity estimate of the association with post-discharge mortality (-0.7% -1.4% to -0.0%) was significant and suggested benefit in this subgroup of patients. CONCLUSIONS In an integrated health system, the implementation of a comprehensive readmissions prevention intervention was associated with a reduction in 30 day readmission rates. Moreover, there was no association with 30 day post-discharge mortality, except among medium risk patients, where some evidence for benefit was found. Altogether, the study provides evidence to suggest the effectiveness of readmission prevention interventions in community settings, but further research might be required to confirm the findings beyond this setting.
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Affiliation(s)
- Ben J Marafino
- Biomedical Informatics Training Program, Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, CA, USA
| | - Gabriel J Escobar
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Michael T Baiocchi
- Department of Epidemiology and Population Health, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Vincent X Liu
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Critical Care Medicine, Kaiser Permanente Medical Center, Santa Clara, CA, USA
| | - Colleen C Plimier
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Alejandro Schuler
- Systems Research Initiative, Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Biomedical Data Science, School of Medicine, Stanford University, Stanford, CA, USA
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Hojilla JC, Hurley LB, Marcus JL, Silverberg MJ, Skarbinski J, Satre DD, Volk JE. Characterization of HIV Preexposure Prophylaxis Use Behaviors and HIV Incidence Among US Adults in an Integrated Health Care System. JAMA Netw Open 2021; 4:e2122692. [PMID: 34436609 PMCID: PMC8391097 DOI: 10.1001/jamanetworkopen.2021.22692] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Long-term follow-up is needed to evaluate gaps in HIV preexposure prophylaxis (PrEP) care delivery and to identify individuals at risk for falling out of care. OBJECTIVE To characterize the PrEP continuum of care, including prescription, initiation, discontinuation, and reinitiation, and evaluate incident HIV infections. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the electronic health records (EHR) at Kaiser Permanente Northern California to identify individuals aged 18 years and older who received PrEP care between July 2012 and March 2019. Individuals were followed up from date of linkage (defined as a PrEP referral or PrEP-coded encounter) until March 2019, HIV diagnosis, discontinuation of health plan membership, or death. Data were analyzed from December 2019 to January 2021. EXPOSURES Sociodemographic factors included age, sex, race and ethnicity, and neighborhood deprivation index, and clinical characteristics were extracted from the EHR. MAIN OUTCOMES AND MEASURES The primary outcomes were attrition at each step of the PrEP continuum of care and incident HIV infections. RESULTS Among 13 906 individuals linked to PrEP care, the median (interquartile range [IQR]) age was 33 (27-43) years, 6771 individuals (48.7%) were White, and 13 227 (95.1%) were men. Total follow-up was 26 210 person-years (median [IQR], 1.6 [0.7-2.8] years). Of individuals linked to PrEP care, 88.1% (95% CI, 86.1%-89.9%) were prescribed PrEP and of these, 98.2% (95% CI, 97.2%-98.8%) initiated PrEP. After PrEP initiation, 52.2% (95% CI, 48.9%-55.7%) discontinued PrEP at least once during the study period, and 60.2% (95% CI, 52.2%-68.3%) of these individuals subsequently reinitiated. Compared with individuals aged 18 to 25 years, older individuals were more likely to receive a PrEP prescription (eg, age >45 years: hazard ratio [HR], 1.21 [95% CI, 1.14-1.29]) and initiate PrEP (eg, age >45 years: HR, 1.09 [95% CI, 1.02-1.16]) and less likely to discontinue (eg, age >45 years: HR, 0.46 [95% CI, 0.42-0.52]). Compared with White patients, African American and Latinx individuals were less likely to receive a PrEP prescription (African American: HR, 0.74 [95% CI, 0.69-0.81]; Latinx: HR, 0.88 [95% CI, 0.84-0.93]) and initiate PrEP (African American: HR, 0.87 [95% CI, 0.80-0.95]; Latinx: HR, 0.90 [95% CI, 0.86-0.95]) and more likely to discontinue (African American: HR, 1.36 [95% CI, 1.17-1.57]; Latinx: 1.33 [95% CI, 1.22-1.46]). Similarly, women, individuals with lower neighborhood-level socioeconomic status (SES), and persons with a substance use disorder (SUD) were less likely to be prescribed (women: HR, 0.56 [95% CI, 0.50-0.62]; lowest SES: HR, 0.72 [95% CI, 0.68-0.76]; SUD: HR, 0.88 [95% CI, 0.82-0.94]) and initiate PrEP (women: HR, 0.71 [95% CI, 0.64-0.80]; lower SES: HR, 0.93 [95% CI, 0.87-.0.99]; SUD: HR, 0.88 [95% CI, 0.81-0.95]) and more likely to discontinue (women: HR, 1.99 [95% CI, 1.67-2.38]); lower SES: HR, 1.40 [95% CI, 1.26-1.57]; SUD: HR, 1.23 [95% CI, 1.09-1.39]). HIV incidence was highest among individuals who discontinued PrEP and did not reinitiate PrEP (1.28 [95% CI, 0.93-1.76] infections per 100 person-years). CONCLUSIONS AND RELEVANCE These findings suggest that gaps in the PrEP care continuum were concentrated in populations disproportionately impacted by HIV, including African American individuals, Latinx individuals, young adults (aged 18-25 years), and individuals with SUD. Comprehensive strategies to improve PrEP continuum outcomes are needed to maximize PrEP impact and equity.
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Affiliation(s)
- J. Carlo Hojilla
- Division of Research, Kaiser Permanente Northern California, Oakland
- Weill Institute for Neurosciences, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Leo B. Hurley
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Julia L. Marcus
- Department of Population Medicine, Harvard Medical School, Boston, Massachusetts
- Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | | | - Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Infectious Diseases, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, Oakland
- Weill Institute for Neurosciences, Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Jonathan E. Volk
- Department of Adult and Family Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California
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Kincaid MW, Peters ZJ, Curry JC. Data-driven approaches to care delivery: Actionable informatics in the DoD's primary care behavioral health program. Fam Syst Health 2021; 39:66-76. [PMID: 34014731 DOI: 10.1037/fsh0000583] [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] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Transforming administrative health care data into meaningful metrics has been critical to the implementation of the Department of Defense's Primary Care Behavioral Health (PCBH) program. METHODS Data from clinical encounters with PCBH providers are used to develop metrics of program performance collaboratively. Metrics focus on describing the PCBH program and patients, provider fidelity to the model, and provider performance. These metrics form two key deliverables: a monitoring dashboard for program managers and a training dashboard for expert trainers conducting site visits. RESULTS Behavioral health consultants (BHCs) conducted nearly 200,000 encounters with more than 100,000 unique patients in fiscal year 2019 at more than 170 locations in 6 countries and 37 states. Administrative data derived from these encounters were used to create a variety of metrics that describe practice and performance at both the provider and program levels. These metrics are delivered through a variety of analytic products to stakeholders who use that information to make data-driven decisions about program direction and provider training. DISCUSSION We discuss examples of program management decisions and expert trainer actions based on these dashboards, highlighting the benefits of continued collaboration between analysts and program managers. Specifically, excerpts from several dashboards illustrate how penetration and productivity metrics yield specific, tailored action plans to improve care delivery and provider performance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
- Melissa W Kincaid
- Psychological Health Center of Excellence, Research and Development Directorate (J-9), Defense Health Agency
| | - Zachary J Peters
- Psychological Health Center of Excellence, Research and Development Directorate (J-9), Defense Health Agency
| | - Justin C Curry
- Psychological Health Center of Excellence, Research and Development Directorate (J-9), Defense Health Agency
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8
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Zerden LDS, Lombardi BM, Richman EL, Fraher EP, Shoenbill KA. Harnessing the electronic health record to advance integrated care. Fam Syst Health 2021; 39:77-88. [PMID: 34014732 DOI: 10.1037/fsh0000584] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Integrated health care is utilized in primary care clinics to meet patients' physical, behavioral, and social needs. Current methods to collect and evaluate the effectiveness of integrated care require refinement. Using informatics and electronic health records (EHR) to distill large amounts of clinical data may help researchers measure the impact of integrated care more efficiently. This exploratory pilot study aimed to (a) determine the feasibility of using EHR documentation to identify behavioral health and social care components of integrated care, using social work as a use case, and (b) develop a lexicon to inform future research using natural language processing. METHOD Study steps included development of a preliminary lexicon of behavioral health and social care interventions to address basic needs, creation of an abstraction guide, identification of appropriate EHR notes, manual chart abstraction, revision of the lexicon, and synthesis of findings. RESULTS Notes (N = 647) were analyzed from a random sample of 60 patients. Notes documented behavioral health and social care components of care but were difficult to identify due to inconsistencies in note location and titling. Although the interventions were not described in detail, the outcomes of screening, referral, and brief treatment were included. The integrated care team frequently used EHR to share information and communicate. DISCUSSION Opportunities and challenges to using EHR data were identified and need to be addressed to better understand the behavioral health and social care interventions in integrated care. To best leverage EHR data, future research must determine how to document and extract pertinent information about integrated team-based interventions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | - Erica L Richman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Erin P Fraher
- Cecil G. Sheps Center for Health Services Research, Department of Family Medicine, University of North Carolina at Chapel Hill
| | - Kimberly Ann Shoenbill
- School of Medicine, Department of Family Medicine, University of North Carolina at Chapel Hill
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Ramalingam S, Dinan MA, Crawford J. Treatment at Integrated Centers Might Bridge the Academic-Community Survival Gap in Patients With Metastatic Non-Small Cell Carcinoma of the Lung. Clin Lung Cancer 2021; 22:e646-e653. [PMID: 33582071 DOI: 10.1016/j.cllc.2020.12.013] [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: 08/10/2020] [Revised: 12/14/2020] [Accepted: 12/29/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Non-small cell lung cancer (NSCLC) is responsible for the most cancer-related deaths in the United States. A better understanding of treatment-related disparities and ways to address them are important to improving survival for patients with metastatic NSCLC. MATERIALS AND METHODS We performed a retrospective analysis using the National Cancer Database. Included in this analysis were 107,116 patients with metastatic NSCLC who were treated at academic centers (AC), community-based centers (CC), and integrated centers (IC) between 2004 and 2015. The primary end point was overall survival, with comparisons of AC, CC, and IC. RESULTS The survival disparity between AC and CC continued to grow over the study period, from a 5.7% difference in 2-year survival to a 7.5% difference. Treatment at IC was initially associated with survival similar to CC (hazard ratio [HR], 0.93), however, later in the study period treatment at IC improved (HR, 0.74) outpacing the improvement in survival in CC (HR, 0.82) but not to the same degree as the improvement in AC (HR, 0.64). The improvement in survival at IC was noted predominantly in patients with adenocarcinoma (HR, 0.72; P < .001) but not in squamous-cell carcinoma (HR, 0.89; P value not significant). CONCLUSION Treatment of metastatic NSCLC at IC was associated with improved survival during our study period compared with treatment at CC. This appeared to be histology-dependent, suggesting a treatment-related improvement in survival because over this period newer therapies were preferentially available for adenocarcinoma. Integrating care across treatment facilities might be one way to bridge the growing gap in survival between AC and CC.
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Mæhle PM, Small Hanto IK, Smeland S. Practicing Integrated Care Pathways in Norwegian Hospitals: Coordination through Industrialized Standardization, Value Chains, and Quality Management or an Organizational Equivalent to Improvised Jazz Standards. Int J Environ Res Public Health 2020; 17:E9199. [PMID: 33317088 PMCID: PMC7764546 DOI: 10.3390/ijerph17249199] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 11/26/2022]
Abstract
The goal of coordinating pathways for cancer patients through their diagnostic and treatment journey is often approached by borrowing strategies from traditional industries, including standardization, process redesign, and variation reduction. However, the usefulness of these strategies is sometimes limited in the face of the complexity and uncertainty that characterize these processes over time and the situation at both patient and institutional levels. We found this to be the case when we did an in-depth qualitative study of coordination processes in patient pathways for three diagnoses in four Norwegian hospitals. What allows these hospitals to accomplish coordination is supplementing standardization with improvisation. This improvisation is embedded in four types of emerging semi-formal structures: collegial communities, networks, boundary spanners, and physical proximity. The hierarchical higher administrative levels appear to have a limited ability to manage and support coordination of these emerging structures when needed. We claim that this can be explained by viewing line management as representative of an economic-administrative institutional logic while these emerging structures represent a medical-professional logic that privileges proximity to the variation and complexity in the situations. The challenge is then to find a way for emergent and formal structures to coexist.
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Affiliation(s)
- Per Magnus Mæhle
- Institute of Health and Society, Faculty of Medicine, University of Oslo, 0314 Oslo, Norway
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Ingrid Kristine Small Hanto
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
| | - Sigbjørn Smeland
- Comprehensive Cancer Centre, Division of Cancer Medicine, Oslo University Hospital, 0450 Oslo, Norway; (I.K.S.H.); (S.S.)
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
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Silverberg MJ, Levine-Hall T, Hood N, Anderson AN, Alexeeff SE, Lam JO, Slome SB, Flamm JA, Hare CB, Ross T, Justice A, Sterne JA, Williams A, Bryant KJ, Weisner CM, Horberg MA, Sterling SA, Satre DD. Health System-Based Unhealthy Alcohol Use Screening and Treatment Comparing Demographically Matched Participants With and Without HIV. Alcohol Clin Exp Res 2020; 44:2545-2554. [PMID: 33067802 PMCID: PMC7725961 DOI: 10.1111/acer.14481] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/08/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Unhealthy alcohol use among persons living with HIV (PLWH) is linked to significant morbidity, and use of alcohol services may differ by HIV status. Our objective was to compare unhealthy alcohol use screening and treatment by HIV status in primary care. METHODS Cohort study of adult (≥18 years) PLWH and HIV-uninfected participants frequency matched 20:1 to PLWH by age, sex, and race/ethnicity who were enrolled in a large integrated healthcare system in the United States, with information ascertained from an electronic health record. Outcomes included unhealthy alcohol screening, prevalence, provider-delivered brief interventions, and addiction specialty care visits. Other predictors included age, sex, race/ethnicity, neighborhood deprivation index, depression, smoking, substance use disorders, Charlson comorbidity index, prior outpatient visits, insurance type, and medical facility. Cox proportional hazards models were used to compute hazard ratios (HR) for the outcomes of time to unhealthy alcohol use screening and time to first addiction specialty visit. Poisson regression with robust standard errors was used to compute prevalence ratios (PR) for other outcomes. RESULTS 11,235 PLWH and 227,320 HIV-uninfected participants were included. By 4.5 years after baseline, most participants were screened for unhealthy alcohol use (85% of PLWH and 93% of HIV-uninfected), but with a lower rate among PLWH (adjusted HR 0.84, 95% CI 0.82 to 0.85). PLWH were less likely, compared with HIV-uninfected participants, to report unhealthy drinking among those screened (adjusted PR 0.74, 95% CI 0.69 to 0.79), and among those who screened positive, less likely to receive brief interventions (adjusted PR 0.82, 95% CI 0.75 to 0.90), but more likely (adjusted HR 1.7, 95% CI 1.2 to 2.4) to have an addiction specialty visit within 1 year. CONCLUSIONS Unhealthy alcohol use was lower in PLWH, but the treatment approach by HIV status differed. PLWH reporting unhealthy alcohol use received less brief interventions and more addiction specialty care than HIV-uninfected participants.
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Affiliation(s)
- Michael J. Silverberg
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Nicole Hood
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Alexandra N. Anderson
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Stacey E. Alexeeff
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Jennifer O. Lam
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Sally B. Slome
- Oakland Medical Center, KPNC, 3801 Howe Street, Oakland, CA 94611, USA
| | - Jason A. Flamm
- Sacramento Medical Center, KPNC, 2345 Fair Oaks Boulevard, Sacramento, CA 95825, USA
| | - C. Bradley Hare
- San Francisco Medical Center, KPNC, 2238 Geary Boulevard, San Francisco, CA 94115, USA
| | - Thekla Ross
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Amy Justice
- Yale School of Medicine, Yale University, 950 Campbell Avenue, West Haven, CT 06516, USA
- VA Connecticut Healthcare System, 950 Campbell Avenue, West Haven, CT 06516, USA
| | - Jonathan A.C. Sterne
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN, UK
| | - Andrew Williams
- Tufts Medical Center, 35 Kneeland Street, Boston MA 02111, USA
| | - Kendall J. Bryant
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 6700B Rockledge Drive, Bethesda, MD 20892-6902, USA
| | - Constance M. Weisner
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Michael A. Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, 2101 East Jefferson Street, 3 West, Rockville, MD 20852, USA
| | - Stacy A. Sterling
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
| | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California (KPNC), 2000 Broadway, Oakland CA, 94612, USA
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94131, USA
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12
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Kranz AM, DeYoreo M, Eshete‐Roesler B, Damberg CL, Totten M, Escarce JJ, Timbie JW. Health system affiliation of physician organizations and quality of care for Medicare beneficiaries who have high needs. Health Serv Res 2020; 55 Suppl 3:1118-1128. [PMID: 33020920 PMCID: PMC7720706 DOI: 10.1111/1475-6773.13570] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/01/2022] Open
Abstract
OBJECTIVE To test the hypothesis that health systems provide better care to patients with high needs by comparing differences in quality between system-affiliated and nonaffiliated physician organizations (POs) and to examine variability in quality across health systems. DATA SOURCES 2015 Medicare Data on Provider Practice and Specialty linked physicians to POs. Medicare Provider Enrollment, Chain, and Ownership System (PECOS) and IRS Form 990 data identified health system affiliations. Fee-for-service Medicare enrollment and claims data were used to examine quality. STUDY DESIGN This cross-sectional analysis of beneficiaries with high needs, defined as having more than twice the expected spending of an average beneficiary, examined six quality measures: continuity of care, follow-up visits after hospitalizations and emergency department (ED) visits, ED visits, all-cause readmissions, and ambulatory care-sensitive hospitalizations. Using a matched-pair design, we estimated beneficiary-level regression models with PO random effects to compare quality of care in system-affiliated and nonaffiliated POs. We then limited the sample to system-affiliated POs and estimated models with system random effects to examine variability in quality across systems. PRINCIPAL FINDINGS Among 2 323 301 beneficiaries with high needs, 52.3% received care from system-affiliated POs. Rates of ED visits were statistically significantly different in system-affiliated POs (117.5 per 100) and nonaffiliated POs (106.8 per 100, P < .0001). Small differences in the other five quality measures were observed across a range of sensitivity analyses. Among systems, substantial variation was observed for rates of continuity of care (90% of systems had rates between 70.8% and 89.4%) and follow-up after ED visits (90% of systems had rates between 56.9% and 73.5%). CONCLUSIONS Small differences in quality of care were observed among beneficiaries with high needs receiving care from system POs and nonsystem POs. Health systems may not confer hypothesized quality advantages to patients with high needs.
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Affiliation(s)
| | | | | | | | | | - José J. Escarce
- David Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
- UCLA Fielding School of Public HealthLos AngelesCaliforniaUSA
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Machta RM, D. Reschovsky J, Jones DJ, Kimmey L, Furukawa MF, Rich EC. Health system integration with physician specialties varies across markets and system types. Health Serv Res 2020; 55 Suppl 3:1062-1072. [PMID: 33284522 PMCID: PMC7720709 DOI: 10.1111/1475-6773.13584] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To examine system integration with physician specialties across markets and the association between local system characteristics and their patterns of physician integration. DATA SOURCES Data come from the AHRQ Compendium of US Health Systems and IQVIA OneKey database. STUDY DESIGN We examined the change from 2016 to 2018 in the percentage of physicians in systems, focusing on primary care and the 10 most numerous nonhospital-based specialties across the 382 metropolitan statistical areas (MSAs) in the US. We also categorized systems by ownership, mission, and payment program participation and examined how those characteristics were related to their patterns of physician integration in 2018. DATA COLLECTION/EXTRACTION METHODS We examined local healthcare markets (MSAs) and the hospitals and physicians that are part of integrated systems that operate in these markets. We characterized markets by hospital and insurer concentration and systems by type of ownership and by whether they have an academic medical center (AMC), a 340B hospital, or accountable care organization. PRINCIPAL FINDINGS Between 2016 and 2018, system participation increased for primary care and the 10 other physician specialties we examined. In 2018, physicians in specialties associated with lucrative hospital services were the most commonly integrated with systems including hematology-oncology (57%), cardiology (55%), and general surgery (44%); however, rates varied substantially across markets. For most specialties, high market concentration by insurers and hospital-systems was associated with lower rates of physician integration. In addition, systems with AMCs and publicly owned systems more commonly affiliated with specialties unrelated to the physicians' potential contribution to hospital revenue, and investor-owned systems demonstrated more limited physician integration. CONCLUSIONS Variation in physician integration across markets and system characteristics reflects physician and systems' motivations. These integration strategies are associated with the financial interests of systems and other strategic goals (eg, medical education, and serving low-income populations).
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Lince-Deroche N, Leuner R, Kgowedi S, Moolla A, Madlala S, Manganye P, Xhosa B, Govathson C, White Ndwanya T, Long L. Voices from the front lines: A qualitative study of integration of HIV, tuberculosis, and primary healthcare services in Johannesburg, South Africa. PLoS One 2020; 15:e0230849. [PMID: 33031399 PMCID: PMC7544124 DOI: 10.1371/journal.pone.0230849] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 03/10/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In South Africa, in 2013-2014, provision of antiretroviral treatment (ART) shifted in some areas from NGOs to public facilities. Tuberculosis (TB) management has also been integrated into public services. We aimed to explore the opinions and experiences of service managers and healthcare providers regarding integration of HIV and TB services into primary healthcare services. METHODS The study sites included three clinics in one peri-urban/urban administrative region of Johannesburg. From March 2015 to August 2016, trained interviewers conducted semi-structured interviews with purposively selected participants. Participants were eligible if they were city/regional managers, clinic managers, or healthcare providers responsible for HIV, TB, non-communicable diseases, or sexual and reproductive health at the three study sites. We used a grounded theory approach for iterative, qualitative analysis, and produced descriptive statistics for quantitative data. RESULTS We interviewed 19 individuals (nine city/regional managers, three clinic managers, and seven nurses). Theoretical definitions of integration varied, as did actual practice. Integration of HIV treatment had been anticipated, but only occurred when required due to shifts in funding for ART. The change was rapid, and some clinics felt unprepared. That said, nearly all respondents were in favor of integrated care. Perceived benefits included comprehensive case management, better client-nurse interactions, and reduced stigma. Barriers to integration included staff shortages, insufficient training and experience, and outdated clinic infrastructure. There were also concerns about the impact of integration on staff workloads and waiting times. Finally, there were concerns about TB integration due to infection control issues. DISCUSSION Integration is multi-faceted and often contingent on local, if not site-specific, factors. In the future in South Africa and in other settings contending with health service reorganization, staff consultations prior to and throughout phase-in of services changes could contribute to improved understanding of operational requirements, including staff needs, and improved patient outcomes.
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Affiliation(s)
- Naomi Lince-Deroche
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- * E-mail:
| | - Rahma Leuner
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sharon Kgowedi
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Aneesa Moolla
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Sinethemba Madlala
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Pertunia Manganye
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Barbara Xhosa
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Caroline Govathson
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Takiyah White Ndwanya
- Faculty of Health Sciences, Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Lawrence Long
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts, United States of America
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Lim LL, Lau ESH, Ozaki R, Chung H, Fu AWC, Chan W, Kong APS, Ma RCW, So WY, Chow E, Cheung KKT, Yau T, Chow CC, Lau V, Yue R, Ng S, Zee B, Goggins W, Oldenburg B, Clarke PM, Lau M, Wong R, Tsang CC, Gregg EW, Wu H, Tong PCY, Ko GTC, Luk AOY, Chan JCN. Association of technologically assisted integrated care with clinical outcomes in type 2 diabetes in Hong Kong using the prospective JADE Program: A retrospective cohort analysis. PLoS Med 2020; 17:e1003367. [PMID: 33007052 PMCID: PMC7531841 DOI: 10.1371/journal.pmed.1003367] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 08/26/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Diabetes outcomes are influenced by host factors, settings, and care processes. We examined the association of data-driven integrated care assisted by information and communications technology (ICT) with clinical outcomes in type 2 diabetes in public and private healthcare settings. METHODS AND FINDINGS The web-based Joint Asia Diabetes Evaluation (JADE) platform provides a protocol to guide data collection for issuing a personalized JADE report including risk categories (1-4, low-high), 5-year probabilities of cardiovascular-renal events, and trends and targets of 4 risk factors with tailored decision support. The JADE program is a prospective cohort study implemented in a naturalistic environment where patients underwent nurse-led structured evaluation (blood/urine/eye/feet) in public and private outpatient clinics and diabetes centers in Hong Kong. We retrospectively analyzed the data of 16,624 Han Chinese patients with type 2 diabetes who were enrolled in 2007-2015. In the public setting, the non-JADE group (n = 3,587) underwent structured evaluation for risk factors and complications only, while the JADE (n = 9,601) group received a JADE report with group empowerment by nurses. In a community-based, nurse-led, university-affiliated diabetes center (UDC), the JADE-Personalized (JADE-P) group (n = 3,436) received a JADE report, personalized empowerment, and annual telephone reminder for reevaluation and engagement. The primary composite outcome was time to the first occurrence of cardiovascular-renal diseases, all-site cancer, and/or death, based on hospitalization data censored on 30 June 2017. During 94,311 person-years of follow-up in 2007-2017, 7,779 primary events occurred. Compared with the JADE group (136.22 cases per 1,000 patient-years [95% CI 132.35-140.18]), the non-JADE group had higher (145.32 [95% CI 138.68-152.20]; P = 0.020) while the JADE-P group had lower event rates (70.94 [95% CI 67.12-74.91]; P < 0.001). The adjusted hazard ratios (aHRs) for the primary composite outcome were 1.22 (95% CI 1.15-1.30) and 0.70 (95% CI 0.66-0.75), respectively, independent of risk profiles, education levels, drug usage, self-care, and comorbidities at baseline. We reported consistent results in propensity-score-matched analyses and after accounting for loss to follow-up. Potential limitations include its nonrandomized design that precludes causal inference, residual confounding, and participation bias. CONCLUSIONS ICT-assisted integrated care was associated with a reduction in clinical events, including death in type 2 diabetes in public and private healthcare settings.
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Affiliation(s)
- Lee-Ling Lim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Eric S. H. Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
| | - Risa Ozaki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Harriet Chung
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
| | - Amy W. C. Fu
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
| | - Wendy Chan
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Alice P. S. Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Ronald C. W. Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Wing-Yee So
- Hospital Authority Head Office, Hong Kong SAR, China
| | - Elaine Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Kitty K. T. Cheung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Tiffany Yau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - C. C. Chow
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Vanessa Lau
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
| | - Rebecca Yue
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Shek Ng
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Benny Zee
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - William Goggins
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Brian Oldenburg
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Philip M. Clarke
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Maggie Lau
- Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong SAR, China
| | - Rebecca Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - C. C. Tsang
- Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong SAR, China
| | - Edward W. Gregg
- School of Public Health, Imperial College London, London, United Kingdom
| | - Hongjiang Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Peter C. Y. Tong
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Gary T. C. Ko
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Andrea O. Y. Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Juliana C. N. Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Asia Diabetes Foundation, Shatin, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
- * E-mail:
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Marotta C, Lochoro P, Pizzol D, Putoto G, Mazzucco W, Saracino A, Monno L, Di Gennaro F, Ictho J. Capacity assessment for provision of quality sexual reproductive health and HIV-integrated services in Karamoja, Uganda. Afr Health Sci 2020; 20:1053-1065. [PMID: 33402951 PMCID: PMC7751512 DOI: 10.4314/ahs.v20i3.8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Sexual and reproductive health (SRH) and Human Immunodeficiency Virus (HIV) are crucial global health issues. Uganda continues to sustain a huge burden of HIV and AIDS. METHODS A cross-sectional health facility-based assessment was performed in November and December 2016 in Karamoja Region, northern Uganda. All the 126 health facilities (HFs) in Karamoja, including 5 hospitals and 121 Health Centers (HCs), covering 51 sub-counties of the 7 districts were assessed. We assessed the capacity of a) leadership and governance, b) human resource, c) service delivery, d) SRH and HIV service integration and e) users satisfaction and perceptions. RESULTS 64% of the established health staffing positions were filled leaving an absolute gap of 704 units in terms of human resources. As for service delivery capacity, on 5 domains assessed, the best performing was basic hygiene and safety measures in which 33% HCs scored "excellent", followed by the presence of basic equipment. The level of integration of SRH/HIV services was 55.56%. CONCLUSION HFs in Karamoja have capacity gaps in a number of health system building blocks. Many of these gaps can be addressed through improved planning. To invest in improvements for these services would have a great gain for Uganda.
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Affiliation(s)
- Claudia Marotta
- University of Palermo, Department of Science for Health Promotion and Mother to Child Care “G. D'Alessandro”, Palermo, Italy
| | | | - Damiano Pizzol
- Doctors With Africa Cuamm, Research Section Padua, Italy
| | | | - Walter Mazzucco
- University of Palermo, Department of Science for Health Promotion and Mother to Child Care “G. D'Alessandro”, Palermo, Italy
| | | | - Laura Monno
- Clinic of Infectious Diseases, University of Bari, Italy
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Parcesepe AM, Lancaster K, Edelman EJ, DeBoni R, Ross J, Atwoli L, Tlali M, Althoff K, Tine J, Duda SN, Wester CW, Nash D. Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017. PLoS One 2020; 15:e0237772. [PMID: 32853246 PMCID: PMC7451518 DOI: 10.1371/journal.pone.0237772] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 08/02/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes. METHODS We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys. RESULTS In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively). CONCLUSION Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.
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Affiliation(s)
- Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Kathryn Lancaster
- Department of Epidemiology, The Ohio State University, Columbus, Ohio, United States of America
| | - E Jennifer Edelman
- Yale School of Medicine, New Haven, Connecticut, United States of America
- Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Raquel DeBoni
- National Institute of Infectology, Evandro Chagas, Fiocruz, Brazil
| | - Jeremy Ross
- TREAT Asia/amfAR, The Foundation for AIDS Research, Bangkok, Thailand
| | - Lukoye Atwoli
- Department of Mental Health, Moi University School of Medicine, Eldoret, Kenya
| | - Mpho Tlali
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Keri Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Judicaël Tine
- Maladies Infectieuses du Centre Hospitalier, National Universitaire de FANN, Dakar, Senegal
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - C William Wester
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Global Health (VIGH), Nashville, Tennessee, United States of America
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, New York, United States of America
- Department of Epidemiology and Biostatistics, City University of New York, New York, New York, United States of America
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Powell CB, Laurent C, Ciaravino G, Garcia C, Han L, Hoodfar E, Karlea A, Kobelka C, Lee J, Littell RD, Roh J, Vay A, Kushi LH. Streamlining genetic testing for women with ovarian cancer in a Northern California health care system. Gynecol Oncol 2020; 159:221-228. [PMID: 32778409 DOI: 10.1016/j.ygyno.2020.07.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 06/03/2020] [Accepted: 07/18/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Referral to Genetics for pre-testing counseling may be inefficient for women with ovarian cancer. This study assesses feasibility of gynecologic oncologists directly offering genetic testing. METHODS A prospective pilot study was conducted at two gynecologic oncology hubs in an integrated healthcare system from May 1 to November 6, 2019. Gynecologic oncologists offered multigene panel testing to women with newly diagnosed ovarian cancer, followed by selective genetic counseling. Outcomes were compared between study participants and women from other hubs in the health system. RESULTS Of ovarian cancer patients at study sites, 40 participated and all underwent genetic testing. Of 101 patients diagnosed at other sites, 85% were referred to genetics (p = .0061 compared to pilot participants) and 67% completed testing (p < .0001). The time from diagnosis to blood draw and notification of result was 18.5 and 34 days for the pilot group compared to 25.5 and 53 days at other sites. Panel testing detected 9 (22.5%) and 7 (10.3%, p = .08) pathogenic mutations in each group, respectively. Patients and providers were highly satisfied with the streamlined process. CONCLUSION Genetic testing performed at the gynecologic oncology point of care for patients with ovarian cancer is feasible, increases uptake of testing, and improves time to results.
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Affiliation(s)
- C Bethan Powell
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America; Kaiser Permanente Northern California Gynecologic Cancer Program San Francisco, United States of America.
| | - Cecile Laurent
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Giuseppe Ciaravino
- Kaiser Permanente Northern California Gynecologic Cancer Program Oakland, United States of America
| | - Christine Garcia
- Kaiser Permanente Northern California Gynecologic Cancer Program San Francisco, United States of America
| | - Liz Han
- Kaiser Permanente Northern California Gynecologic Cancer Program Oakland, United States of America
| | - Elizabeth Hoodfar
- Kaiser Permanente Northern California Genetics Department, United States of America
| | - Audrey Karlea
- Kaiser Permanente Northern California Genetics Department, United States of America
| | - Christine Kobelka
- Kaiser Permanente Northern California Genetics Department, United States of America
| | - Jaimie Lee
- Kaiser Permanente Oakland Obstetrics and Gynecology Residency Program, United States of America
| | - Ramey D Littell
- Kaiser Permanente Northern California Gynecologic Cancer Program San Francisco, United States of America
| | - Janise Roh
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
| | - Agniezka Vay
- Kaiser Permanente Northern California Gynecologic Cancer Program Oakland, United States of America
| | - Lawrence H Kushi
- Kaiser Permanente Northern California, Division of Research, Oakland, CA, United States of America
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Machta RM, Reschovsky J, Jones DJ, Furukawa MF, Rich EC. Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model? Health Serv Res 2020; 55:541-547. [PMID: 32700385 PMCID: PMC7375995 DOI: 10.1111/1475-6773.13313] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model. DATA SOURCES We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas. STUDY DESIGN We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR. PRINCIPAL FINDINGS Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant. CONCLUSIONS When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.
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D'haenens F, Helsloot K, Lauwaert K, Agache L, de Velde GV, De Frène V, Embo M, Vermeulen J, Beeckman K, Fobelets M. Towards an integrated perinatal care pathway for vulnerable women: The development and validation of quality indicators. Midwifery 2020; 89:102794. [PMID: 32668387 DOI: 10.1016/j.midw.2020.102794] [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: 01/08/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Development and validation of a set of quality indicators for vulnerable women during the perinatal period. DESIGN A three-phase method was used. Phase 1 consisted of a literature review to identify publications for the development of care domains and potential QIs, as well as a quality assessment by the research team. In phase 2 an expert panel assessed the set of concept QIs in a modified three-round Delphi survey. Finally, semi-structured interviews with vulnerable women were conducted as a final quality assessment of a set of indicators (phase 3). Ethical approval was obtained from the ethics committee of the University Hospital Brussels and from the Ethics Committees of all the participating hospitals. SETTING The Flemish Region and the Brussels Capital Region in Belgium. PARTICIPANTS Healthcare and social care professionals (n = 40) with expertise in the field of perinatal care provision for vulnerable families. Vulnerable women (n = 11) who gave birth in one of the participating hospitals. FINDINGS The literature review resulted in a set of 49 potential quality indicators in five care domains: access to healthcare, assessment and screening, informal support, formal support and continuity of care. After assessment by the expert panel and vulnerable women, a final set of 21 quality indicators in five care domains was identified. First of all, organisation of care must involve an integrated multidisciplinary approach taking account of financial, administrative and social barriers (care domain 1: access to healthcare). Second, qualitative care includes the timely initiation of care, a general screening of the various aspects of vulnerability (biological, psychological, social and cognitive) and a risk assessment for all women (care domain 2: assessment and screening). Vulnerable women benefit from intensive formal and informal support taking account of individual needs and strengths (care domain 3: formal support; care domain 4: informal support). Finally, continuity of care needs to be guaranteed in line with vulnerable woman's individual needs (care domain 5: continuity of care). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Implementing quality indicators in existing and new care pathways offers an evidence-based approach facilitating an integrated view promoting a healthy start for woman and child. These quality indicators can assist healthcare providers, organisations and governmental agencies to improve the quality of perinatal care for vulnerable women.
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Affiliation(s)
- Florence D'haenens
- Midwifery Department, Department Health Care, Knowledge Centre Brussels Integrated Care, Erasmus Brussels University of Applied Sciences and Arts, Belgium.
| | - Kaat Helsloot
- Midwifery Department, Artevelde University of Applied Sciences, Ghent, Belgium.
| | - Karen Lauwaert
- Midwifery Department, Artevelde University of Applied Sciences, Ghent, Belgium.
| | - Lien Agache
- Social Care Department, Artevelde University of Applied Sciences, Ghent, Belgium.
| | - Griet Van de Velde
- Midwifery Department, Artevelde University of Applied Sciences, Ghent, Belgium; Midwifery Department, Department Health Care, Knowledge Centre Brussels Integrated Care, Erasmus Brussels University of Applied Sciences and Arts, Belgium.
| | - Veerle De Frène
- Midwifery Department, Artevelde University of Applied Sciences, Ghent, Belgium.
| | - Mieke Embo
- Midwifery Department, Artevelde University of Applied Sciences, Ghent, Belgium.
| | - Joeri Vermeulen
- Midwifery Department, Department Health Care, Knowledge Centre Brussels Integrated Care, Erasmus Brussels University of Applied Sciences and Arts, Belgium; Department of Public Health, Biostatistics and Medical Informatics, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Belgium.
| | - Katrien Beeckman
- University Hospital Brussels, Nursing and Midwifery Research Unit, Belgium; Vrije Universiteit Brussel (VUB), Nursing and Midwifery Research Unit, Faculty of Medicine and Pharmacy & Universitair Ziekenhuis Brussel, Belgium; Verpleeg- en vroedkunde, Centre for Research and Innovation in Care, Midwifery Research Education and Policymaking (MIDREP), Universiteit Antwerpen, Belgium.
| | - Maaike Fobelets
- Department of Public Health, Biostatistics and Medical Informatics, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Belgium; Department Health Care, Knowledge Centre Brussels Integrated Care, Erasmus Brussels University of Applied Sciences and Arts, Belgium.
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21
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Molling D, Vincent BM, Wiitala WL, Escobar GJ, Hofer TP, Liu VX, Rosen AK, Ryan AM, Seelye S, Prescott HC. Developing a template matching algorithm for benchmarking hospital performance in a diverse, integrated healthcare system. Medicine (Baltimore) 2020; 99:e20385. [PMID: 32541458 PMCID: PMC7302661 DOI: 10.1097/md.0000000000020385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 11/23/2022] Open
Abstract
Template matching is a proposed approach for hospital benchmarking, which measures performance based on matching a subset of comparable patient hospitalizations from each hospital. We assessed the ability to create the required matched samples and thus the feasibility of template matching to benchmark hospital performance in a diverse healthcare system.Nationwide Veterans Affairs (VA) hospitals, 2017.Observational cohort study.We used administrative and clinical data from 668,592 hospitalizations at 134 VA hospitals in 2017. A standardized template of 300 hospitalizations was selected, and then 300 hospitalizations were matched to the template from each hospital.There was substantial case-mix variation across VA hospitals, which persisted after excluding small hospitals, hospitals with primarily psychiatric admissions, and hospitalizations for rare diagnoses. Median age ranged from 57 to 75 years across hospitals; percent surgical admissions ranged from 0.0% to 21.0%; percent of admissions through the emergency department, 0.1% to 98.7%; and percent Hispanic patients, 0.2% to 93.3%. Characteristics for which there was substantial variation across hospitals could not be balanced with any matching algorithm tested. Although most other variables could be balanced, we were unable to identify a matching algorithm that balanced more than ∼20 variables simultaneously.We were unable to identify a template matching approach that could balance hospitals on all measured characteristics potentially important to benchmarking. Given the magnitude of case-mix variation across VA hospitals, a single template is likely not feasible for general hospital benchmarking.
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Affiliation(s)
- Daniel Molling
- VA Center for Clinical Management Research, Ann Arbor, MI
| | | | | | - Gabriel J. Escobar
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Timothy P. Hofer
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Amy K. Rosen
- VA Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA
| | - Andrew M. Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI
| | - Sarah Seelye
- VA Center for Clinical Management Research, Ann Arbor, MI
| | - Hallie C. Prescott
- VA Center for Clinical Management Research, Ann Arbor, MI
- Department of Internal Medicine, University of Michigan
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22
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Bui-Duy MK, Wong S, Lam R, Karliner LS. Development of a Multistep Hypertension Quality Improvement Program in an Academic General Medicine Practice. J Healthc Qual 2020; 41:172-179. [PMID: 31094951 DOI: 10.1097/jhq.0000000000000158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Hypertension is a common problem and a major risk factor for cardiovascular disease. It is unclear whether efforts to control blood pressure (BP) known to be effective in integrated healthcare systems can be successfully implemented in an academic setting. We describe our experience implementing a multistep quality improvement program within an academic general medicine practice aimed at improving BP among patients with uncontrolled hypertension. Ensuring medical assistants were correctly measuring BP provided the basis for accurate data entry into the electronic medical record (EMR); our EMR-based registry data allowed us to feedback primary care provider (PCP) level data on BP control for panel management, which resulted in improvements in BP for a substantial proportion of patients, particularly for those with more practice visits. However, due to PCP, patient, and system barriers, our initial attempt to integrate a pharmacist into our team for hypertension management was only successful for a small number of patients who engaged in pharmacist in-person visits. Future improvement efforts will focus on addressing the barriers to more intensive BP management, integrating lessons from this experience. As chronic disease management shifts to a population-based model, team change will be a necessary component for achieving clinical improvement.
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Yaqoob M, Wang J, Sweeney AT, Wells C, Rego V, Jaber BL. Trends in Avoidable Hospitalizations for Diabetes: Experience of a Large Clinically Integrated Health Care System. J Healthc Qual 2020; 41:125-133. [PMID: 31094945 DOI: 10.1097/jhq.0000000000000145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Prevention quality indicators (PQIs) are used in hospital discharge data sets to identify quality of care for ambulatory care-sensitive conditions, such as diabetes. We examined the impact of clinical integration efforts on diabetes-related PQIs in a large community-based health care organization. Inpatient and observation hospitalizations from nine acute care hospitals were trended over 5 years (2012-2016). Using established technical specifications, annual hospitalizations rates were calculated for four diabetes-related PQIs: uncontrolled diabetes, short-term complications, long-term complications, and lower extremity amputations. The mean (±standard error of the mean) annual hospitalization rate for uncontrolled diabetes and short-term complications gradually increased from 1.3 ± 1.1 and 3.2 ± 2.5 per 1,000 discharges to 2.4 ± 1.7 (p < .001) and 7.1 ± 3.2 (p < .001) per 1,000 discharges, respectively. Conversely, the annual hospitalization rate for long-term complications and lower extremity amputations gradually decreased from 12.6 ± 1.1 and 88.6 ± 1.0 per 1,000 discharges to 6.5 ± 1.0 (p = .004) and 82.2 ± 1.0 per 1,000 discharges (p < .001). Trends generally persisted across payers, age, sex, and race. There was an inverse correlation between county income-per-capita and hospitalization rate for short-term complications (p = .04), long-term complications (p = .03), and lower extremity amputations (p < .001). Study limitations included use of administrative data, evolving coding practices, and ecological fallacy. Ambulatory-based efforts to optimize diabetes care can prevent long-term complications and reduce avoidable hospitalizations.
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Zubatsky M, Runyan C, Gulotta S, Knight JR, Pettinelli JD. Burnout among behavioral health providers in integrated care settings. Fam Syst Health 2020; 38:74-82. [PMID: 31789532 DOI: 10.1037/fsh0000456] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Burnout in health care, especially among physicians, is a growing concern. It is now well accepted that physician burnout leads to increased depersonalization of patients, lower personal accomplishment, employee turnover, and worse patient outcomes. What is not known, however, is to what extent behavioral health providers (BHPs) in medical settings experience burnout and its associated sequela. METHOD Participants (n = 230) from a variety of practice settings and levels of integrated care completed practice and burnout questions via an online survey. Practice-related questions and a modified version of the Maslach Burnout Inventory was administered to BHPs who work in different levels of collaboration with other medical providers. RESULTS Overall, BHPs who work primarily in fully integrated care settings reported higher rates of personal accomplishment in their everyday job (B = 1.49; 95% confidence interval [CI] = 0.40, 2.58). Additionally, those who have worked more than 10 years in these types of settings reported both higher personal accomplishment (B = 1.58; 95% CI = 0.68, 2.49) and lower rates of depersonalization (B = -1.32; 95% CI = -2.28, -0.36). DISCUSSION In contrast to high rates of burnout among many clinicians in the United States, this is the first study to document relatively low rates of reported burnout among integrated care BHPs. The relationships between lower burnout, working in a fully integrated care practice, and experience as a BHP is important to understand when creating and sustaining team-based primary care jobs. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
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Affiliation(s)
- Max Zubatsky
- Department of Family and Community Medicine, Saint Louis University
| | - Christine Runyan
- Department of Family Medicine and Community Health, University of Massachusetts Medical Center
| | - Samantha Gulotta
- Department of Family and Community Medicine, Saint Louis University
| | - Jeanna R Knight
- Department of Family and Community Medicine, Saint Louis University
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Abstract
OBJECTIVE To assess the reliability and validity of a shortened version of the Rainbow Model of Integrated Care (RMIC) measurement tool (MT). The original version of the measurement tool has been modified (shortened) for the Australian context. DESIGN Validation of the psychometric properties of the RMIC-MT. SETTING Healthcare providers providing services to a geographically defined rural area in New South Wales (NSW), Australia. PARTICIPANTS A sample of 56 healthcare providers providing mental and physical healthcare. MAIN OUTCOME MEASURES The psychometric properties of the tool were tested using principal component analysis for validity and Cronbach's alpha for reliability. RESULTS The tool was shown to have good validity and reliability. The 35 items used in the shortened version of the tool were reduced to 29 items grouped into four dimensions: community-governance orientation, normative integration, functional integration and clinical-professional coordination. CONCLUSIONS The shortened version of the RMIC-MT is a valid and reliable tool that evaluates integrated care from a healthcare provider's perspective in NSW, Australia. In order to assess the tool's appropriateness in an international context, future studies should focus on validating the tool in other healthcare settings.
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Affiliation(s)
- Julian Fares
- Engineering and Information Technologies, Project Management Program, University of Sydney, Sydney, New South Wales, Australia
| | - Kon Shing Kenneth Chung
- Engineering and Information Technologies, Project Management Program, University of Sydney, Sydney, New South Wales, Australia
| | - Megan Passey
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Jo Longman
- University Centre for Rural Health, University of Sydney, Lismore, New South Wales, Australia
| | - Pim P Valentijn
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Integrated Care Evaluation, Essenburgh, Hierden, The Netherlands
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Bernasconi A, Crabbé F, Adedeji AM, Bello A, Schmitz T, Landi M, Rossi R. Results from one-year use of an electronic Clinical Decision Support System in a post-conflict context: An implementation research. PLoS One 2019; 14:e0225634. [PMID: 31790448 PMCID: PMC6886837 DOI: 10.1371/journal.pone.0225634] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 11/08/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In 2017, the Adamawa State Primary Healthcare Development Agency introduced ALMANACH, an electronic clinical decision support system based on a modified version of IMCI. The target area was the Federal State of Adamawa (Nigeria), a region recovering after the Boko Haram insurgency. The aim of this implementation research was to assess the improvement in terms of quality care offered after one year of utilization of the tool. METHODS We carried out two cross-sectional studies in six Primary Health Care Centres to assess the improvements in comparison with the baseline carried out before the implementation. One survey was carried out inside the consultation room and was based on the direct observation of 235 consultations of children aged from 2 to 59 months old. The second survey questioned 189 caregivers outside the health facility for their opinion about the consultation carried out through using the tablet, the prescriptions and medications given. RESULTS In comparison with the baseline, more children were checked for danger signs (60.0% vs. 37.1% at baseline) and in addition, children were actually weighed (61.1% vs. 27.7%) during consultation. Malnutrition screening was performed in 35.1% of children (vs. 12.1%). Through ALMANACH, also performance of preventive measures was significantly improved (p<0.01): vaccination status was checked in 39.8% of cases (vs. 10.6% at baseline), and deworming and vitamin A prescription was increased to 46.5% (vs. 0.7%) and 48.3% (vs. 2.8%) respectively. Furthermore, children received a complete physical examination (58.3% vs. 45.5%, p<0.01) and correct treatment (48.4% vs. 29.5%, p<0.01). Regarding antibiotic prescription, 69.3% patients received at least one antibiotic (baseline 77.7%, p<0.05). CONCLUSIONS Our findings highlight major improvements in terms of quality of care despite many questions still pending to be answered in relation to a full integration of the tool in the Adamawa health system.
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Affiliation(s)
| | - Francois Crabbé
- HTTU, Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Attahiru Bello
- Adamawa State Primary Healthcare Development Agency, Adamawa, Nigeria
| | - Torsten Schmitz
- HTTU, Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Abstract
This cross-sectional study examines racial disparities in the route of hysterectomy for benign indications within an integrated health care system in the United States.
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Affiliation(s)
- Eve Zaritsky
- Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland Medical Center, Oakland
| | - Anthonia Ojo
- Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland Medical Center, Oakland
| | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Tina R Raine-Bennett
- Division of Research, Obstetrics and Gynecology, Kaiser Permanente Northern California, Oakland Medical Center, Oakland
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Abstract
IMPORTANCE Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care. OBJECTIVE To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data. DESIGN, SETTING, AND PARTICIPANTS This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources. EXPOSURES Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives. MAIN OUTCOMES AND MEASURES Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility). RESULTS In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%]; P < .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays. CONCLUSIONS AND RELEVANCE This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.
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Affiliation(s)
- Gabriel J. Escobar
- Systems Research Initiative, Kaiser Permanente Division of Research, Oakland, California
| | - Colleen Plimier
- Systems Research Initiative, Kaiser Permanente Division of Research, Oakland, California
| | - John D. Greene
- Systems Research Initiative, Kaiser Permanente Division of Research, Oakland, California
| | - Vincent Liu
- Systems Research Initiative, Kaiser Permanente Division of Research, Oakland, California
- Intensive Care Unit, Kaiser Permanente Medical Center, Santa Clara, California
| | - Patricia Kipnis
- Systems Research Initiative, Kaiser Permanente Division of Research, Oakland, California
- TPMG Consulting Services, Oakland, California
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Abstract
OBJECTIVE To evaluate the impact of TEAM UP-an initiative that fully integrates behavioral health services into pediatric primary care in three Boston-area Community Health Centers (CHCs)-on health care utilization and costs. DATA SOURCES 2014-2017 claims data on continuously enrolled children from a Massachusetts Medicaid managed care plan. STUDY DESIGN We used a difference-in-difference approach with inverse probability of treatment weights to compare outcomes in children receiving primary care at TEAM UP CHCs versus comparison site CHCs, in the pre (2014-2016q2)- versus post (2016q3-2017)-intervention periods. Utilization outcomes included emergency department visits, inpatient admissions, primary care visits, and outpatient/professional visits (all cause and those with mental health (MH) diagnoses). Cost outcomes included total cost of care (inpatient, outpatient, professional, pharmacy). We further assessed differential effects by baseline MH diagnosis. PRINCIPAL FINDINGS After 1.5 years, TEAM UP was associated with a relative increase in the rate of primary care visits (IRR = 1.15, 95% CI 1.04-1.27, or 115 additional visits/1000 patients/quarter), driven by children with a MH diagnosis at baseline. There was no significant change in avoidable health care utilization or cost. CONCLUSIONS Expanding the TEAM UP behavioral health integration model to other sites has the potential to improve primary care engagement in low-income children with MH needs.
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Affiliation(s)
- Megan B. Cole
- Department of Health Law, Policy, and ManagementBoston University School of Public HealthBostonMassachussets
| | - Qiuyuan Qin
- Department of PediatricsBoston Medical CenterBostonMassachussets
| | - Radley C. Sheldrick
- Department of Health Law, Policy, and ManagementBoston University School of Public HealthBostonMassachussets
| | - Debra S. Morley
- Department of PediatricsBoston Medical CenterBostonMassachussets
| | - Megan H. Bair‐Merritt
- Department of PediatricsBoston Medical CenterBostonMassachussets
- Department of PediatricsBoston University School of MedicineBostonMassachussets
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Wind A, Gonçalves FR, Marosi E, da Pieve L, Groza M, Asioli M, Albini M, van Harten W. Benchmarking Cancer Centers: From Care Pathways to Integrated Practice Units. J Natl Compr Canc Netw 2019; 16:1075-1083. [PMID: 30181419 DOI: 10.6004/jnccn.2018.7035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 04/18/2018] [Indexed: 11/17/2022]
Abstract
Background: Structuring cancer care into pathways can reduce variability in clinical practice and improve patient outcomes. International benchmarking can help centers with regard to development, implementation, and evaluation. A further step in the development of multidisciplinary care is to organize care in integrated practice units (IPUs), encompassing the whole pathway and relevant organizational aspects. However, research on this topic is limited. This article describes the development and results of a benchmark tool for cancer care pathways and explores IPU development in cancer centers. Methods: The benchmark tool was developed according to a 13-step benchmarking method and piloted in 7 European cancer centers. Centers provided data and site visits were performed to understand the context in which the cancer center operates and to clarify additional questions. Benchmark data were structured into pathway development and evaluation and assessed against key IPU features. Results: Benchmark results showed that most centers have formalized multidisciplinary pathways and that care teams differed in composition, and found almost 2-fold differences in mammography use efficiency. Suggestions for improvement included positioning pathways formally and structurally evaluating outcomes at a sufficiently high frequency. Based on the benchmark, 3 centers indicating that they had a breast cancer IPU were scored differently on implementation. Overall, we found that centers in Europe are in various stages of development of pathways and IPUs, ranging from an informal pathway structure to a full IPU-type of organization. Conclusions: A benchmark tool for care pathways was successfully developed and tested, and is available in an open format. Our tool allows for the assessment of pathway organization and can be used to assess the status of IPU development. Opportunities for improvement were identified regarding the organization of care pathways and the development toward IPUs. Three centers are in varying degrees of implementation and can be characterized as breast cancer IPUs. Organizing cancer care in an IPU could yield multiple performance improvements.
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van Overveld LFJ, Takes RP, Braspenning JCC, Baatenburg de Jong RJ, de Boer JP, Brouns JJA, Bun RJ, Dik EA, van Dijk BAC, van Es RJJ, Hoebers FJP, Kolenaar B, Kropveld A, Langeveld TPM, Verschuur HP, de Visscher JGAM, van Weert S, Witjes MJH, Smeele LE, Merkx MAW, Hermens RPMG. Variation in Integrated Head and Neck Cancer Care: Impact of Patient and Hospital Characteristics. J Natl Compr Canc Netw 2019; 16:1491-1498. [PMID: 30545996 DOI: 10.6004/jnccn.2018.7061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 07/17/2018] [Indexed: 11/17/2022]
Abstract
Background: Monitoring and effectively improving oncologic integrated care requires dashboard information based on quality registrations. The dashboard includes evidence-based quality indicators (QIs) that measure quality of care. This study aimed to assess the quality of current integrated head and neck cancer care with QIs, the variation between Dutch hospitals, and the influence of patient and hospital characteristics. Methods: Previously, 39 QIs were developed with input from medical specialists, allied health professionals, and patients' perspectives. QI scores were calculated with data from 1,667 curatively treated patients in 8 hospitals. QIs with a sample size of >400 patients were included to calculate reliable QI scores. We used multilevel analysis to explain the variation. Results: Current care varied from 29% for the QI about a case manager being present to discuss the treatment plan to 100% for the QI about the availability of a treatment plan. Variation between hospitals was small for the QI about patients discussed in multidisciplinary team meetings (adherence: 95%, range 88%-98%), but large for the QI about malnutrition screening (adherence: 50%, range 2%-100%). Higher QI scores were associated with lower performance status, advanced tumor stage, and tumor in the oral cavity or oropharynx at the patient level, and with more curatively treated patients (volume) at hospital level. Conclusions: Although the quality registration was only recently launched, it already visualizes hospital variation in current care. Four determinants were found to be influential: tumor stage, performance status, tumor site, and volume. More data are needed to assure stable results for use in quality improvement.
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Valentijn PP, Pereira F, Sterner CW, Vrijhoef HJM, Ruwaard D, Hegbrant J, Strippoli GFM. Validation of the Rainbow Model of Integrated Care Measurement Tools (RMIC-MTs) in renal care for patient and care providers. PLoS One 2019; 14:e0222593. [PMID: 31536548 PMCID: PMC6752779 DOI: 10.1371/journal.pone.0222593] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 09/03/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Integrated service delivery is considered to be an essential condition for improving the management and health outcomes of people with chronic kidney disease (CKD). However, research on the assessment of integrated care by patients and care providers is hindered by the absence of brief, reliable, and valid measurement tools. OBJECTIVE The aim of this study was to develop survey instruments for healthcare professionals and patients based on the Rainbow Model of Integrated Care (RMIC), and to evaluate their psychometric properties. DESIGN The development process was based on the US Food and Drug Administration guidelines. This included item generation from systematic reviews of existing tools and expert opinion on clarity and content validity, involving renal care providers and chronic kidney patients. A cross-sectional, multi-centre design was used to test for internal consistency and construct validity. SETTING Outpatient clinics in a large renal network. PARTICIPANTS A sample of 30.788 CKD patients, and 8.914 renal care providers. METHODS AND ANALYSIS Both survey instruments were developed using previous qualitative work and published literature. A multidisciplinary expert panel assessed the face and content validity of both instruments and following a pilot study, the psychometric properties of both instruments were explored. Exploratory factor analysis with principal axis factoring and with promax rotation was used to assess the underlying dimensions of both instruments; Cronbach's alpha was used to determine the internal constancy reliability. RESULTS 17.512 patients (response rate: 56.9%) and 8.849 care providers (response rate: 69.5%) responded to the questionnaires. Factor analysis of the patient questionnaire yielded three internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, clinical coordination, and professional coordination. Factor analysis of the provider questionnaire produced eight internally consistent (Cronbach's alpha > 0.7) factors: person-centeredness, community centeredness, clinical coordination, professional coordination, organisational coordination, system coordination, technical and cultural competence. As hypothesised, care coordination patient and providers scores significantly correlated with questions about quality of care, treatment involvement, reported health, clinics' organisational readiness, and external care coordination capacity. CONCLUSION This study provides evidence for the reliability and validity of the RMIC patient and provider questionnaires as generic tools to assess the experience with or perception of integrated renal care delivery. The instruments are recommended in future applications testing test-retest reliability, convergent and predictive validity, and responsiveness.
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Affiliation(s)
- Pim P. Valentijn
- Department of Patient and Care, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Integrated Care Evaluation, Essenburgh, Hierden, The Netherlands
| | | | | | - Hubertus J. M. Vrijhoef
- Department of Patient and Care, Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Family Medicine, Vrije Universiteit Brussel, Brussels, Belgium
- Panaxea, Amsterdam, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Jörgen Hegbrant
- Diaverum Medical Scientific Office, Diaverum Sweden AB, Lund, Sweden
| | - Giovanni F. M. Strippoli
- Diaverum Medical Scientific Office, Diaverum Sweden AB, Lund, Sweden
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Zhao M, Liu B, Shan L, Li C, Wu Q, Hao Y, Chen Z, Lan L, Kang Z, Liang L, Ning N, Jiao M. Can integration reduce inequity in healthcare utilization? Evidence and hurdles in China. BMC Health Serv Res 2019; 19:654. [PMID: 31500617 PMCID: PMC6734466 DOI: 10.1186/s12913-019-4480-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 08/28/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Integration of medical insurance schemes has been prioritized as one of the key strategies to address inequity in China's health system. The first pilot attempt to integrate started in 2003 and later expanded nationwide. This study aims to assess its intended impact on inequity in inpatient service utilization and identify the main determinants contributing to its ineffectiveness. METHODS A total of 49,365 respondents in the pilot integrated area and 77,165 respondents in the non-integration area were extracted from the Fifth National Health Services Survey. A comparative analysis was conducted between two types of areas. We calculate a concentration index (CI) and horizontal inequity index (HI) in inpatient service utilization and decompose the two indices. RESULTS Insurance integration played a positive role in reducing inequality in inpatient service utilization to some extent. A 13.23% lower in HI, a decrease in unmet inpatient care and financial barriers to inpatient care in the pilot integrated area compared with the non-integration area; decomposition analysis showed that the Urban-Rural Residents Basic Medical Insurance, a type of integrated insurance, contributed 37.49% to reducing inequality in inpatient service utilization. However, it still could not offset the strong negative effect of income and other insurance schemes that have increased inequality. CONCLUSIONS The earlier pilot attempt for integrating medical insurance was not enough to counteract the influence of factors which increased the inequality in inpatient service utilization. Further efforts to address the inequality should focus on widening access to financing, upgrading the risk pool, reducing gaps within and between insurance schemes, and providing broader chronic disease benefit packages. Social policies that target the needs of the poor with coordinated efforts from various levels and agencies of the government are urgently needed.
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Affiliation(s)
- Miaomiao Zhao
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
- Department of Health Management, School of Public Health, Nantong University, 9 Seyuan Road, Chongchuan District, Nantong, 226019, Jiangsu, China
| | - Baohua Liu
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Linghan Shan
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Cui Li
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Qunhong Wu
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.
| | - Yanhua Hao
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China.
| | - Zhuo Chen
- Department of Health Policy and Management College of Public Health, University of Georgia, Athens, GA, 30602, USA
- School of Economics, Faculty of Humanities and Social Sciences, University of Nottingham Ningbo, 199 Taikang East Road, Ningbo, Zhejiang, 315100, China
| | - Lan Lan
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Zheng Kang
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Libo Liang
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Ning Ning
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
| | - Mingli Jiao
- Department of Social Medicine, School of Health Management, Harbin Medical University, 157 Baojian Road, Nangang District, Harbin, 150086, Heilongjiang, China
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Joseph N, Talwar C, Sikdar I, Sengupta M, Sayed DA, Mahajan I. Experiences and Perceptions Toward Integrative, Complementary, and Alternative Medicine Among Conventional Medicine Practitioners of Mangalore, India. J Manipulative Physiol Ther 2019; 42:492-502. [PMID: 31864434 DOI: 10.1016/j.jmpt.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 12/17/2018] [Accepted: 12/19/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Nitin Joseph
- Department of Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Mangalore, Karnataka State, India.
| | - Chhavi Talwar
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka State, India
| | - Isha Sikdar
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka State, India
| | - Manjima Sengupta
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka State, India
| | - Daanish Ali Sayed
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka State, India
| | - Ishika Mahajan
- Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka State, India
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Oldham MA, Chahal K, Lee HB. A systematic review of proactive psychiatric consultation on hospital length of stay. Gen Hosp Psychiatry 2019; 60:120-126. [PMID: 31404826 DOI: 10.1016/j.genhosppsych.2019.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes. METHOD We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes. RESULTS Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model. CONCLUSIONS Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.
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Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
| | - Khushminder Chahal
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America
| | - Hochang B Lee
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America
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Herrinton LJ, Woodworth TS, Eworuke E, Amsden LB, Liu L, Wyeth J, Petrone A, Menzin TJ, Williams J, Goldfien R, Nguyen M. Development of an algorithm to detect methotrexate wrong frequency error using computerized health care data. Pharmacoepidemiol Drug Saf 2019; 28:1361-1368. [PMID: 31410932 DOI: 10.1002/pds.4858] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 05/07/2019] [Accepted: 06/12/2019] [Indexed: 11/07/2022]
Abstract
PURPOSE We validated an algorithm to detect frequency errors in computerized healthcare data and estimated the incidence of these errors in an integrated healthcare system. METHODS We applied Sentinel System analytic tools on the electronic health records of Kaiser Permanente, Northern California, January 1, 2010, through May 30, 2015,to identify rheumatoid arthritis (RA) patients with new use of methotrexate (365-day baseline period). We identified potential methotrexate frequency errors using ICD-9 code 995.20 (adverse drug event), Current Procedural Terminology (CPT) code 96409 for injection of leucovorin and prescription refill patterns. We performed chart review to confirm the frequency errors, assessed performance for detecting frequency errors, and estimated the incidence of chart-confirmed errors. RESULTS The study included 24,529 methotrexate dispensings among 3,668 RA patients. Among these, 722 (3%) had one dispensing and 23,807 (97.1%) had ≥2 dispensings during 1-year follow-up period. We flagged 653 (2.7%) with a potential medication error (46 with one dispensing and 607 with ≥2 dispensings). We sampled 94 for chart review, and confirmed three methotrexate errors. All three confirmed frequency errors involved a first methotrexate dispensing followed by injected rescue therapy, leucovorin, (positive predictive value, 60%; 95% confidence interval [CI], 15-95%). No potential errors were found among patients with ≥2 dispensings. We estimated the frequency error incidence among one methotrexate dispensing to be 0.4% (95%CI, 0.1% to 1.2%). CONCLUSION Rescue therapy is a specific indicator of methotrexate overdose among first methotrexate dispensings. This method is generalizable to other medications with serious adverse events treated with antidotes.
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Affiliation(s)
- Lisa J Herrinton
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Tiffany S Woodworth
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Efe Eworuke
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
| | - Laura B Amsden
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Liyan Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Jo Wyeth
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
| | - Andrew Petrone
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Talia J Menzin
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - James Williams
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | - Robert Goldfien
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael Nguyen
- Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD
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Thompson H, Faig W, Gupta N, Lahey R, Golden R, Pollack M, Karnik N. Collaborative Care for Depression of Adults and Adolescents: Measuring the Effectiveness of Screening and Treatment Uptake. Psychiatr Serv 2019; 70:604-607. [PMID: 31023189 PMCID: PMC6602801 DOI: 10.1176/appi.ps.201800257] [Citation(s) in RCA: 6] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study analyzed effectiveness of screening, referrals, and treatment uptake of a collaborative care for depression intervention across 10 primary care clinics in Chicago. METHODS Between November 2016 and December 2017, patients (N=25,369) were screened with the Patient Health Questionnaire-2 and the Patient Health Questionnaire-9 on the basis of an eligibility algorithm. Electronic health record data were analyzed for sample characteristics, screening rates, referrals, and treatment pathways. To identify disparities, a test of proportions was conducted between eligible and screened patients as well as referred and treated patients. RESULTS Screenings, referrals, and uptake occurred proportionately across subgroups except for patients ages 12-17. Adolescent age was associated with disproportionate Patient Health Questionnaire-9 screenings and with treatment disengagement. CONCLUSIONS The intervention shows promise in expanding access to care and reducing disparities. Greater access to psychotherapies and innovative treatment modalities, particularly for adolescents, may improve overall treatment uptake.
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Affiliation(s)
- Hale Thompson
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Walter Faig
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Neha Gupta
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Rebecca Lahey
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Robyn Golden
- Department of Social Work & Community Health, Rush University Medical Center, Chicago, IL USA
| | - Mark Pollack
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
| | - Niranjan Karnik
- Department of Psychiatry & Behavioral Sciences, Rush Medical College, Rush University, Chicago, IL USA
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Poot AJ, Wopereis DM, den Elzen WPJ, Gussekloo J, Blom JW. Changes in patient satisfaction related to their perceived health state during implementation of improved integrated care for older persons. PLoS One 2019; 14:e0216028. [PMID: 31095590 PMCID: PMC6522052 DOI: 10.1371/journal.pone.0216028] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/12/2019] [Indexed: 11/19/2022] Open
Abstract
Patient satisfaction with the general practitioner (GP) is lower in older persons with a higher level of complexity of health problems. This study investigates whether, in these older persons, changes in satisfaction with their GP, on receiving improved integrated care, is related to their perceived health state.Using the Integrated Systematic Care for Older People (ISCOPE) trial (aimed at improving person- centered integrated care) this study compared changes in satisfaction with the GP in older persons (aged ≥75 years) with a high level of complex health problems on receiving integrated care, stratified for perceived health state at baseline. Satisfaction with the GP was registered on a 5-point Likert scale. Perceived health state was estimated with the Older Persons and Informal Caregivers Survey-Composite End Point (TOPICS-CEP) at baseline, stratified into 33% percentiles. Differences in satisfaction change between the intervention and usual care/control groups (overall and stratified for perceived health state) are presented by percentages of 'very satisfied' participants and improving or deteriorating 1 or more points on the Likert scale. At baseline, the intervention (n = 151) and control group (n = 603) were mainly female (75%) and living alone (62%); mean age was 83 years. Medical status, perceived health state and characteristics of participants were similar. Overall, at baseline 44.4% of respondents in the intervention group were 'very satisfied' compared with 37.1% at follow-up, (difference -7.3%). In the control group, 'very satisfied' at baseline was 32% and at follow up 29.2% (difference -2.8%). The p-value for this difference in change is 0.56. After stratification for TOPICS-CEP the results were the same. In older persons with a high level of complexity of health problems, implementation of person- centered integrated healthcare did not influence their satisfaction with the GP, also not among those with the highest or lowest perceived health state.
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Affiliation(s)
- Antonius J. Poot
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Daisy M. Wopereis
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Wendy P. J. den Elzen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeanet W. Blom
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
IMPORTANCE Clinician compassion is a vital element of health care quality. Currently, there appears to be no validated and feasible method for health care organizations to measure patient assessment of clinician compassion on a large scale. OBJECTIVE To develop and validate a tool for measuring patient assessment of clinician compassion that can be used in conjunction with the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey. DESIGN, SETTING, AND PARTICIPANTS This prospective cohort study took place from June 1 to August 30, 2018, at a US academic health care system among a pilot cohort consisting of 3325 adult patients and a validation cohort consisting of 3483 adult patients, both of whom had an outpatient clinic visit and completed the CG-CAHPS survey. MAIN OUTCOMES AND MEASUREMENTS After a comprehensive literature review, 12 candidate survey items were developed. Face and construct validity were performed. Candidate items were disseminated to patients in conjunction with the CG-CAHPS survey in a series of 2 studies: (1) exploratory factor analysis in one cohort to determine the factor structure and the most parsimonious set of items; and (2) validity testing in a second cohort using confirmatory factor analysis. Reliability was tested using Cronbach α. Convergent validity was tested with patient assessment of clinician communication and overall satisfaction questions from CG-CAHPS survey. RESULTS Overall, 6493 patient responses were analyzed. The mean (SD) age was 60 (15) years, 4239 patients (65.3%) were women, and 5079 (78.2%) were white. Exploratory factor analyses identified a 5-item compassion measure to be the most parsimonious. Confirmatory factor analyses found good fit. The compassion measure demonstrated good internal consistency (α = 0.94) and convergent validity (clinician communication: ρ = 0.44; overall satisfaction: ρ = 0.52) but reflected a patient experience domain (compassionate care) distinct from what is currently captured in the CG-CAHPS survey. CONCLUSIONS AND RELEVANCE A simple 5-item tool to measure patient assessment of clinician compassion was developed and validated for use in conjunction with CG-CAHPS survey.
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Affiliation(s)
- Brian W. Roberts
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
- Center for Humanism, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Michael B. Roberts
- Institutional Research and Outcomes Assessment, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Jady Yao
- Department of Patient Family Centered Care, Cooper University Health Care, Camden, New Jersey
| | - Joshua Bosire
- Department of Patient Family Centered Care, Cooper University Health Care, Camden, New Jersey
| | - Anthony Mazzarelli
- Department of Emergency Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
- Center for Humanism, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Stephen Trzeciak
- Center for Humanism, Cooper Medical School of Rowan University, Camden, New Jersey
- Department of Medicine, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
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Forder J, Gousia K, Saloniki EC. The impact of long-term care on primary care doctor consultations for people over 75 years. Eur J Health Econ 2019; 20:375-387. [PMID: 30187252 PMCID: PMC6438947 DOI: 10.1007/s10198-018-0999-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 08/14/2018] [Indexed: 06/08/2023]
Abstract
Many countries are adopting policies to create greater coordination and integration between acute and long-term care services. This policy is predicated on the assumption that these service areas have interdependent outcomes for patients. In this paper, we study the interdependencies between the long-term (home care) services and consultations with a primary care doctor, as used by people over 75 years. Starting with a model of individual's demand for doctor consultations, given supply, we formalize the hypothesis that exogenous increases to home care supply will reduce the number of consultations where these services are technical substitutes. Furthermore, greater coordination of public service planning and use of pooled budgets could lead to better outcomes because planners can account for these externalities. We test our main hypothesis using data from the British Household Panel Study for 1991-2009. To address potential concerns about endogeneity, we use a set of instrumental variables for home care motivated by institutional features of the social care system. We find that there is a statistically significant substitution effect between home care and doctor visits, which is robust across a range of specifications. This result has implications for policies that consider increased coordination between health care and social care systems.
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Affiliation(s)
- Julien Forder
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK
| | - Katerina Gousia
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK.
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, CT2 7NX, UK.
| | - Eirini-Christina Saloniki
- Personal Social Services Research Unit, University of Kent, Canterbury, Kent, CT2 7NX, UK
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, CT2 7NX, UK
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Exley J, Abel GA, Fernandez JL, Pitchforth E, Mendonca S, Yang M, Roland M, McGuire A. Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis. BMJ Open 2019; 9:e024220. [PMID: 30833317 PMCID: PMC6443075 DOI: 10.1136/bmjopen-2018-024220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.
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Affiliation(s)
- Josephine Exley
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, Cambridgeshire, UK
| | - Gary A Abel
- University of Exeter Medical School, Exeter, UK
| | - José-Luis Fernandez
- Personal Social Services Research Unit, London School of Economics, London, UK
| | | | - Silvia Mendonca
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Miaoqing Yang
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, Cambridgeshire, UK
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics, London, UK
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Nielsen M, Levkovich N. Promoting health payment reform literacy: Does integrated care save money? Fam Syst Health 2019; 37:74-83. [PMID: 30920263 DOI: 10.1037/fsh0000402] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Under the current payment environment, the challenges to implementing and sustaining integrated behavioral health care are substantial. One key barrier for clinicians, administrators, researchers, and patients/families is a lack of clarity about who pays for integrated health care in the United States, and a lack of consensus about whether bending the health care cost curve is a fundamental goal of integrated care, and for whom. Clinicians caring for patients and families in integrated care settings would benefit from honing their "payment reform literacy skills" in order to advocate for integrated care. METHOD This paper offers a primer on the current state of health care spending in the United States, an overview of public and private payers, and the challenges each faces in paying for integrated care. DISCUSSION Future journal articles in the FSH Policy and Management Department will describe key payment policy and management opportunities for integrated care payment reform. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Teng A, Blakely T, Scott N, Jansen R, Masters-Awatere B, Krebs J, Oetzel J. What protects against pre-diabetes progressing to diabetes? Observational study of integrated health and social data. Diabetes Res Clin Pract 2019; 148:119-129. [PMID: 30633935 DOI: 10.1016/j.diabres.2018.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/15/2018] [Accepted: 12/12/2018] [Indexed: 01/08/2023]
Abstract
AIMS To examine the incidence of type 2 diabetes in people with newly diagnosed prediabetes and the factors that protect against this progression. METHODS The study population was 14,043 adults with pre-diabetes enrolled in a primary health organization in the upper North Island of New Zealand. Glycated hemoglobin (HbA1c) and body mass index (BMI) were linked to government health, census and social datasets in the Statistics New Zealand Integrated Data Infrastructure. Adults with a first diagnosis of pre-diabetes between 2009 and 2017 (HbA1c in range 5.9-6.6% [41-49 mmol/mol]) were followed-up for type 2 diabetes incidence. Cox regression was used to examine protective factors and adjust for potential confounding. RESULTS Cumulative diabetes incidence was 5.0% after three years. Progression was greater in younger adults, men, people with higher HbA1c, greater BMI and a more recent diagnosis. Progression was lower in people treated with metformin, and Indigenous language speakers. Higher progression rates for Māori (Indigenous population) and Pacific peoples (migrants to New Zealand) were related to higher baseline HbA1c. CONCLUSIONS This is the first study to identify Indigenous language as a protective factor against diabetes, and results confirm obesity as a key target for population prevention. People with identified risk factors should be prioritized for pre-diabetes interventions.
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Affiliation(s)
- Andrea Teng
- University of Otago, Wellington, New Zealand.
| | | | - Nina Scott
- University of Auckland, Waikato District Health Board, New Zealand
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McCoy RG, Bunkers KS, Ramar P, Meier SK, Benetti LL, Nesse RE, Naessens JM. Patient attribution: why the method matters. Am J Manag Care 2018; 24:596-603. [PMID: 30586493 PMCID: PMC6549236] [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 To assess the impact of 5 commonly used patient attribution methods on measured healthcare cost, quality, and utilization metrics within an integrated healthcare delivery system. STUDY DESIGN Cross-sectional analysis of administrative data of all patients attributed (by any of 5 methods) and/or paneled to a primary care provider (PCP) at Mayo Clinic Rochester (MCR) in 2011. METHODS We retrospectively applied 5 attribution methods to MCR administrative data from January 1, 2010, to December 31, 2011. MCR is an integrated healthcare delivery system serving primary care and referral populations. The referral practice is geographically colocated but otherwise distinct from 6 primary care practice sites that include pediatric, internal medicine, and family medicine groups. Patients attributed by each method were compared on their concordance with PCP empanelment, quality measures, healthcare utilization, and total costs of care. RESULTS The 5 methods attributed between 61,813 (42%) and 106,152 (72%) of paneled patients to a PCP at MCR, although not necessarily to the paneled PCP. There was marked variation in care utilization and total costs of care, but not quality measures, among patients attributed by the different methods and between those paneled versus not paneled. Patients with more primary care visits were more likely to be attributed by all methods. CONCLUSIONS Reliable identification of the physician-patient relationship is necessary for accurate evaluation of healthcare processes, efficiencies, and outcomes. Optimization and standardization of attribution methods are therefore essential as health systems, payers, and policy makers seek to evaluate and improve the value of delivered care.
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Affiliation(s)
- Rozalina G McCoy
- Division of Health Care Policy & Research, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
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Bernasconi A, Crabbé F, Raab M, Rossi R. Can the use of digital algorithms improve quality care? An example from Afghanistan. PLoS One 2018; 13:e0207233. [PMID: 30475833 PMCID: PMC6261034 DOI: 10.1371/journal.pone.0207233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 10/27/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Quality of care is a difficult parameter to measure. With the introduction of digital algorithms based on the Integrated Management of Childhood Illness (IMCI), we are interested to understand if the adherence to the guidelines improved for a better quality of care for children under 5 years old. METHODS More than one year after the introduction of digital algorithms, we carried out two cross sectional studies to assess the improvements in comparison with the situation prior to the implementation of the project, in two Basic Health Centres in Kabul province. One survey was carried out inside the consultation room and was based on the direct observation of 181 consultations of children aged 2 months to 5 years old, using a checklist completed by a senior physicians. The second survey queried 181 caretakers of children outside the health facility for their opinion about the consultation carried out through the tablet and prescriptions and medications given. RESULTS We measured the quality of care as adherence to the IMCI's guidelines. The study evaluated the quality of the physical examination and the therapies prescribed with a special attention to antibiotic prescription. We noticed a dramatic improvement (p<0.05) of several indicators following the introduction of digital algorithms. The baseline physical examination was appropriate only for 23.8% [IC% 19.9-28.1] of the patients, 34.5% [IC% 30.0-39.2] received a correct treatment and 86.1% [IC% 82.4-89.2] received at least one antibiotic. With the introduction of digital algorithms, these indicators statistically improved respectively to 84.0% [IC% 77.9-88.6], >85% and less than 30%. CONCLUSIONS Our findings suggest that digital algorithms improve quality of care by applying the guidelines more effectively. Our experience should encourage to test this tool in different settings and to scale up its use at province/state level.
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Affiliation(s)
- Andrea Bernasconi
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - François Crabbé
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Martin Raab
- Swiss TPH, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Rodolfo Rossi
- PHC programs, International Committee of the Red Cross, Genève, Switzerland
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Luo M, Poh Z, Koh G, Tham TY, Lau W, Toh SA, Chong CK, Low LL, Venkataraman K. Diabetes management in a Primary Care Network (PCN) of private general practitioners in Singapore: An observational study. Medicine (Baltimore) 2018; 97:e12929. [PMID: 30412099 PMCID: PMC6221669 DOI: 10.1097/md.0000000000012929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A Primary Care Network (PCN) is a virtual network of general practitioners (GPs), sharing common resources and common clinical governance framework for effective chronic disease management. In this study, we analyzed the frequency of assessment as well as control of HbA1c, blood pressure (BP), and low-density lipoprotein (LDL) over time among adult patients with diabetes managed by a group of private GPs under PCN.Data, including clinical measurements of HbA1c, BP, and LDL from 2012 to 2015, of 943 subjects at 9 GP clinics that piloted PCN in Singapore in 2012 was obtained from the chronic disease register for this analysis.The total number of PCN patients increased from 371 in 2012 to 911 in 2015. The average HbA1c decreased from 7.5% in 2012 to 7.3% in 2015, with a significant yearly improving trend of -0.11% (P < .001). The trends in change for systolic BP and LDL were not statistically significant during the same follow-up period. Regular assessment of HbA1c decreased from 80% in 2012 to 55% in 2015. Such decreases were also found in BP and LDL assessments. We also found that receiving government subsidies under a national scheme was a major determinant for maintaining regular assessment, with patients so covered 3 to 20 times more likely to have regular assessments.The PCN model can help improve care and clinical outcomes in adult patients with diabetes in the private primary care sector. Investing greater financial and human resources to augment service capacity and expanding subsidy coverage may be important to ensure the effectiveness, scalability, and sustainability of such a model of care.
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Affiliation(s)
- Miyang Luo
- Saw Swee Hock School of Public Health, National University of Singapore
| | | | - Gerald Koh
- Saw Swee Hock School of Public Health, National University of Singapore
| | - Tat Yean Tham
- Frontier Healthcare Group
- Yong Loo Lin School of Medicine, National University of Singapore
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Crooks PW, Thomas CO, Compton-Phillips A, Leith W, Sundang A, Zhou YY, Radler L. Clinical outcomes and healthcare use associated with optimal ESRD starts. Am J Manag Care 2018; 24:e305-e311. [PMID: 30325191] [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 the association between optimal end-stage renal disease (ESRD) starts and clinical and utilization outcomes in an integrated healthcare delivery system. STUDY DESIGN Retrospective observational cohort study in 6 regions of an integrated healthcare delivery system, 2011-2013. METHODS Propensity score techniques were used to match 1826 patients who experienced an optimal start of renal replacement therapy (initial therapy of hemodialysis via an arteriovenous fistula or graft, peritoneal dialysis, or pre-emptive transplant) to 1826 patients who experienced a nonoptimal start (hemodialysis via a central venous catheter). Outcomes included 12-month rates of sepsis, mortality, and utilization (inpatient stays, total inpatient days, emergency department visits, and outpatient visits to primary care and specialty care). RESULTS Optimal starts were associated with a 65% reduction in sepsis (odds ratio, 0.35; 95% CI, 0.29-0.42) and a 56% reduction in 12-month mortality (hazard ratio, 0.44; 95% CI, 0.36-0.53). Optimal starts were also associated with lower utilization, except for nephrology visits. Large utilization differences were observed for total inpatient days (9.4 for optimal starts vs 27.5 for nonoptimal starts; relative rate [RR], 0.45; 95% CI, 0.38-0.52) and outpatient visits for specialty care other than nephrology or vascular surgery (12.5 vs 18.3, respectively; RR, 0.62; 95% CI, 0.53-0.74). CONCLUSIONS Compared with patients with nonoptimal starts, patients with optimal ESRD starts have lower morbidity and mortality and less use of inpatient and outpatient care. Late-stage chronic kidney disease and ESRD care in an integrated system may be associated with greater benefits than those previously reported in the literature.
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Affiliation(s)
- Peter W Crooks
- Southern California Permanente Medical Group, 393 E Walnut St, Pasadena, CA 91188.
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Wammes JJG, van der Wees PJ, Tanke MAC, Westert GP, Jeurissen PPT. Systematic review of high-cost patients' characteristics and healthcare utilisation. BMJ Open 2018; 8:e023113. [PMID: 30196269 PMCID: PMC6129088 DOI: 10.1136/bmjopen-2018-023113] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [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] [Received: 03/21/2018] [Revised: 06/05/2018] [Accepted: 07/17/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries. DESIGN Systematic review. DATA SOURCES PubMed and Embase databases were searched until 30 October 2017. ELIGIBILITY CRITERIA AND OUTCOMES Our final search was built on three themes: 'high-cost', 'patients', and 'cost' and 'cost analysis'. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen's behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics. RESULTS The studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients' utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life. CONCLUSIONS High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.
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Affiliation(s)
- Joost Johan Godert Wammes
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Philip J van der Wees
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Marit A C Tanke
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
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Mauricio ECB, Lopes MCBT, Batista REA, Okuno MFP, Campanharo CRV. Results of the implementation of integrated care after cardiorespiratory arrest in a university hospital. Rev Lat Am Enfermagem 2018; 26:e2993. [PMID: 30020334 PMCID: PMC6053291 DOI: 10.1590/1518-8345.2308.2993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 11/26/2017] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES to identify the care measures performed after cardiorespiratory arrest (CRA) and to relate them to the neurological status and survival at four moments: within the first 24 hours, at the discharge, six months after discharge, and one year after discharge. METHOD retrospective, analytical and quantitative study performed at the Emergency Department of a university hospital in São Paulo. Eighty-eight medical records of CRA patients who had a return of spontaneous circulation sustained for more than 20 minutes were included and the post-CRA care measures performed in the first 24 hours were identified, as well as its relationship with survival and neurological status. RESULTS the most frequent post-CRA care measures were use of advanced airway access techniques and indwelling bladder catheterization. Patients who had maintained good breathing and circulation, temperature control and who were transferred to intensive care unit had a better survival in the first 24 hours, after six months and one year after discharge. Good neurological status at six months and one year after discharge was associated with non-use of vasoactive drugs and investigation of the causes of the CRA. CONCLUSION the identification of good practices in post-CRA care may help to reduce the mortality of these individuals and to improve their quality of life.
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Affiliation(s)
| | | | - Ruth Ester Assayag Batista
- PhD, Full Professor, Escola Paulista de Enfermagem, Universidade
Federal de São Paulo, São Paulo, SP, Brazil
| | - Meiry Fernanda Pinto Okuno
- PhD, Assistant Professor, Escola Paulista de Enfermagem,
Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Hedderson MM, Xu F, Sridhar SB, Han ES, Quesenberry CP, Crites Y. A cohort study of maternal cardiometabolic risk factors and primary cesarean delivery in an integrated health system. PLoS One 2018; 13:e0199932. [PMID: 29969472 PMCID: PMC6029787 DOI: 10.1371/journal.pone.0199932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 06/15/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Maternal cardiometabolic risk factors (i.e., hyperglycemia, pre-existing hypertension and high body mass index) impact fetal growth and risk of having a cesarean delivery. However, the independent and joint contribution of maternal cardiometabolic risk factors to primary cesarean section is unclear. We aimed to elucidate the degree to which maternal cardiometabolic risk factors contribute to primary cesarean deliveries and whether associations vary by infant size at birth in an integrated health system. METHODS A cohort study of 185,045 singleton livebirths from 2001 to 2010. Poisson regression with robust standard errors provided crude and adjusted relative risks (RR) and 95% confidence intervals (CIs) for cesarean delivery risk associated with risk factors. We then estimated the proportion of cesarean sections that could be prevented if the cardiometabolic risk factor in pregnant women were eliminated (the population-attributable risk [PAR]). RESULTS In a single multivariable model, maternal cardiometabolic risk factors were independently associated with cesarean delivery: RR (95% CI) abnormal glucose screening 1.04 (1.01-1.08); gestational diabetes 1.18 (1.11-1.18) and pre-existing diabetes 1.60 (1.49-1.71); pre-existing hypertension 1.16 (1.10-1.23); overweight 1.27 (1.24-1.30); obese class I 1.46 (1.42-1.51); obese class II 1.73 (1.67-1.80); and obese class III 1.97 (1.88-2.07); adjusting for established risk factors, medical facility and year. The associations between maternal cardiometabolic risk factors and primary cesarean delivery remained among infants with appropriate weights for gestational age. The PARs were 17.4% for overweight/obesity, 7.0% for maternal hyperglycemia, 2.0% for pre-existing hypertension and 20.5% for any cardiometabolic risk factor. CONCLUSIONS Maternal cardiometabolic risk factors were independently associated with risk of primary cesarean delivery, even among women delivering infants born at an appropriate size for gestational age. Effective strategies to increase the proportion of women entering pregnancy at an optimal weight with normal blood pressure and glucose before pregnancy could potentially eliminate up to 20% of cesarean deliveries.
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Affiliation(s)
- Monique M. Hedderson
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Fei Xu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Sneha B. Sridhar
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Emily S. Han
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Charles P. Quesenberry
- Division of Research, Kaiser Permanente Northern California, Oakland, California, United States of America
| | - Yvonne Crites
- The Kaiser Permanente Northern California Medical Group, Oakland, California, United States of America
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