Health promotion in physician organizations: results from a national study

Physician Practices With Robust Capabilities Spend Less On Medicare Beneficiaries Than More Limited Practices

No research has considered a range of physician practice capabilities for managing patient care when examining practice-level influences on quality of care, utilization, and spending. Using data from the 2017 National Survey of Healthcare Organizations and Systems linked to 2017 Medicare fee-for-service claims data from attributed beneficiaries, we examined the association of practice-level capabilities with process measures of quality, utilization, and spending. In propensity score-weighted mixed-effects regression analyses, physician practice locations with "robust" capabilities had lower total spending compared to locations with "mixed" or "limited" capabilities. Quality and utilization, however, did not differ by practice-level capabilities. Physician practice locations with robust capabilities spend less on Medicare fee-for-service beneficiaries but deliver quality of care that is comparable to the quality delivered in locations with low or mixed capabilities. Reforms beyond those targeting practice capabilities, including multipayer alignment and payment reform, may be needed to support larger performance advantages for practices with robust capabilities.

Achieving Adherence to Evidence-Based Practices

In response to evolving policies and conditions, hospitals have increased health information technology (HIT) adoption and strived to improve hospital–physician integration. While evidence suggests that both HIT and integration confer independent benefits, when combined, they may provide complementary means to achieve high performance or overlap to offset each other’s contribution. We explore this relationship in the context of hospital adherence to evidence-based practices (EBPs). Using the American Hospital Association’s Annual and IT Supplement surveys, and Centers for Medicare and Medicaid Services’s Hospital Compare, we estimate the independent relationships and interactions between HIT and hospital–physician integration with respect to EBP adherence. HIT adoption and tight (but not loose) integration are independently associated with greater adherence to EBPs. The interaction between HIT adoption and tight integration is negative, consistent with an offsetting association between HIT adoption and integration in their relationship to EBP adherence. This finding reveals the need to be aware of potential substitutive effects from simultaneous pursuit of multiple approaches to performance improvement.

Improving System Integration: The Art and Science of Engaging Small Community Practices in Health System Innovation

This paper focuses on successful engagement strategies in recruiting and retaining primary care physicians (PCPs) in a quality improvement project, as perceived by family physicians in small practices. Sustained physician engagement is critical for quality improvement (QI) aiming to enhance health system integration. Although there is ample literature on engaging physicians in hospital or team-based practice, few reports describe factors influencing engagement of community-based providers practicing with limited administrative support. The PCPs we describe participated in

SCOPE

Seamless Care Optimizing the Patient Experience, a QI project designed to support their care of complex patients and reduce both emergency department (ED) visits and inpatient admissions. SCOPE outcome measures will inform subsequent papers. All the 30 participating PCPs completed surveys assessing perceptions regarding the importance of specific engagement strategies. Project team acknowledgement that primary care is challenging and new access to patient resources were the most important factors in generating initial interest in SCOPE. The opportunity to improve patient care via integration with other providers was most important in their commitment to participate, and a positive experience with project personnel was most important in their continued engagement. Our experience suggests that such providers respond well to personalized, repeated, and targeted engagement strategies.

Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings

RATIONALE, AIMS AND OBJECTIVES

Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide.

METHODS

Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed.

RESULTS

A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes.

CONCLUSIONS

There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information.

The effect of personal lifestyle intervention among health care providers on their patients and clinics; the Promoting Health by Self Experience (PHASE) randomized controlled intervention trial

OBJECTIVE

To determine the effect of self-experience multidisciplinary lifestyle intervention on health care providers (HCPs), patients and clinics.

METHODS

We randomized 15 primary-care clinics (serving 93,821 members), matched by patient profile, to provide the HCPs, either intervention or control HMO program. We followed personally 77 HCPs and 496 patients, and evaluated clinical measurement rate (CMR) changes (January-September 2010; Israel).

RESULTS

HCPs within the intervention group demonstrated personal improvement in health initiative attitudes (p<0.05 vs. baseline), and a decrease in salt intake (p<0.05 vs. control). HCP intervention group's patients exhibited overall improvement in dietary patterns, specifically in salt, red meat (p<0.05 vs. baseline), fruit, and vegetable (p<0.05 vs. control) intake. Height, lipids, HbA1(C) and CMR increased within the intervention group's clinics (p<0.05 vs. baseline) with increased referral to angiography tests (p<0.05 vs. control). Within the intervention group, HCPs' salt pattern improvement was associated with increased lipid CMR (r=0.71; p=0.048), and lower HCPs' body weight was associated with increased blood pressure (r=-0.81; p=0.015) and lipid (r=-0.69; p=0.058) CMR.

CONCLUSIONS

HCPs' personal lifestyles are directly correlated with their clinical performance. Interventions to promote health through HCP's self-experience are valuable and somewhat haloed to patients and clinics, suggesting an adjunct strategy in primary prevention.

Small business support of youth physical activity opportunities

PURPOSE

Describe small business support for youth physical activity opportunities (YPAO) and identify factors associated with this support.

DESIGN

Cross-sectional analysis of quantitative data relating business characteristics and support for YPAO.

SETTING

Eight demographically heterogeneous, urban neighborhoods in a Midwest metropolitan area.

SUBJECTS

Adult small business owners (n = 90; 65% response rate; mean age 48.4 years; 73.3% male; 45.2% minority).

MEASURES

Neighborhood demographics from the 2000 U.S. Census and self-reported business and owner characteristics.

ANALYSIS

Multivariate analysis of variance was used to contrast business and owner characteristics between businesses that did and did not support YPAO.

RESULTS

Businesses supporting YPAO had larger annual operating (F = 7.6; p = .018) and advertising budgets (F = 8.5; p = .009) and had younger owners (F = 6.1; p = .034), with sports backgrounds (χ(2) = 5.6; p = .018) and who felt businesses should support YPAO (χ(2) = 3.8; p = .048). Of the 46 businesses not supporting YPAO, 82.6% felt small businesses should support YPAO. The major reasons for nonsupport were difficulty identifying YPAO to support and not being asked for support.

CONCLUSIONS

Business (e.g., budgets) and business owner characteristics (e.g., age), owner connectedness with YPAO, and the approach used for garnering support (active solicitation, clearly defined support mechanism) were associated with supporting YPAO. Additional business (e.g., annual revenues), owner (e.g., perceptions of YPAO), and environmental (e.g., crime rate, land use) factors should be examined as potential correlates.

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BACKGROUND

Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.

METHODS

The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.

RESULTS

One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.

CONCLUSIONS

P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Quality improvement in small office settings: an examination of successful practices

Background

Physicians in small to moderate primary care practices in the United States (U.S.) (<25 physicians) face unique challenges in implementing quality improvement (QI) initiatives, including limited resources, small staffs, and inadequate information technology systems 23,36. This qualitative study sought to identify and understand the characteristics and organizational cultures of physicians working in smaller practices who are actively engaged in measurement and quality improvement initiatives.

Methods

We undertook a qualitative study, based on semi-structured, open-ended interviews conducted with practices (N = 39) that used performance data to drive quality improvement activities.

Results

Physicians indicated that benefits to performing measurement and QI included greater practice efficiency, patient and staff retention, and higher staff and clinician satisfaction with practice. Internal facilitators included the designation of a practice champion, cooperation of other physicians and staff, and the involvement of practice leaders. Time constraints, cost of activities, problems with information management and or technology, lack of motivated staff, and a lack of financial incentives were commonly reported as barriers.

Conclusion

These findings shed light on how physicians engage in quality improvement activities, and may help raise awareness of and aid in the implementation of future initiatives in small practices more generally.

Hospital-physician collaboration: landscape of economic integration and impact on clinical integration

CONTEXT

Hospital-physician relationships (HPRs) are an important area of academic research, given their impact on hospitals' financial success. HPRs also are at the center of several federal policy proposals such as gain sharing, bundled payments, and pay-for-performance (P4P).

METHODS

This article analyzes the HPRs that focus on the economic integration of hospitals and physicians and the goals that HPRs are designed to achieve. It then reviews the literature on the impact of HPRs on cost, quality, and clinical integration.

FINDINGS

The goals of the two parties in HPRs overlap only partly, and their primary aim is not reducing cost or improving quality. The evidence base for the impact of many models of economic integration is either weak or nonexistent, with only a few models of economic integration having robust effects. The relationship between economic and clinical integration also is weak and inconsistent. There are several possible reasons for this weak linkage and many barriers to further integration between hospitals and physicians.

CONCLUSIONS

Successful HPRs may require better financial conditions for physicians, internal changes to clinical operations, application of behavioral skills to the management of HPRs, changes in how providers are paid, and systemic changes encompassing several types of integration simultaneously.

Improving medical practice: a conceptual framework

PURPOSE

The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement.

METHODS

I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement.

RESULTS

My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed.

CONCLUSION

This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.

Large multispecialty group practices and quality improvement: what is needed to transform care?

The objective of this study was to use successful quality improvement initiatives in large multispecialty medical groups to identify the organizational factors that were the most important to improvement. The study analyzed the most successful quality improvement initiatives from those submitted by the 24 members of the Council of Accountable Physician Practices. Twelve initiatives from 8 groups were selected that met the study criteria for large improvement for large numbers of patients. An independent group used these initiatives to identify potentially important factors and then asked key local leaders to rate the importance of these factors on a scale of 1 to 4, importance rating (1-4 scale) for each of 18 identified factors. Eighteen factors were identified and 5 stood out as ranked a 4 (Very Important) for at least 80% of the initiatives: Communication, Use of Evidence-Based Medicine, Leadership, Measurement, and Reporting. Another 7 of the 18 factors were ranked a 4 for more than 50% of the initiatives. All the factors are related to the 6 challenges in the Institute of Medicine report. It was concluded that any organization striving to greatly improve the quality of its healthcare delivery should consider these factors when planning improvement initiatives.

Influence of primary care practice and provider attributes on preventive service delivery

BACKGROUND

While visits to the doctor's office are appropriate times to advise patients on health behaviors, these opportunities are often missed. Lapses in care quality are no longer attributed solely to individuals, but are also increasingly understood to be the result of organizational factors. This research examines the influence that both practice and provider attributes have on the delivery of preventive services for health behaviors.

METHODS

This study used data collected from the Prescription for Health initiative sponsored by the Robert Wood Johnson Foundation. Quantitative data on 52 primary care practices and 318 healthcare providers were gathered from September 2003 to September 2004, and were analyzed upon completion of data collection. Hierarchical linear modeling was used to examine associations between both practice and provider attributes and preventive service delivery.

RESULTS

Practice staff participation in decisions regarding quality improvement, practice change, and clinical operations positively influenced the effect of work relationships and negatively influenced the effect of practice size on service delivery. Nurse practitioners and allied health professionals reported more frequent delivery of services compared to physicians. Last, use of reminder systems and patient registries were positively associated with preventive service delivery.

CONCLUSIONS

This study offers preliminary support for staff participation in practice decisions as a positive aspect of teamwork and collaboration. Findings also suggest leveraging nonphysician clinical staff and organized clinical systems to improve the delivery of preventive services for health behaviors.

Improving quality in Medicaid: the use of care management processes for chronic illness and preventive care

BACKGROUND

Care management processes (CMPs), tools to improve the efficiency and quality of primary care delivery, are particularly important for low-income patients facing substantial barriers to care.

OBJECTIVE

To measure the adoption of CMPs by medical groups, Independent Practice Associations, community clinics, and hospital-based clinics in California's Medicaid program and the factors associated with CMP adoption.

METHODS

Telephone survey of every provider organization with at least 6 primary care physicians and at least 1 Medi-Cal HMO contract, Spring 2003. One hundred twenty-three organizations participated, accounting for 64% of provider organizations serving Medicaid managed care in California. We surveyed 30 measures of CMP use for asthma and diabetes, and for child and adolescent preventive services.

RESULTS

The mean number of CMPs used by each organization was 4.5 for asthma and 4.9 for diabetes (of a possible 8). The mean number of CMPs for preventive services was 4.0 for children and 3.5 for adolescents (of a possible 7). Organizations with more extensive involvement in Medi-Cal managed care used more CMPs for chronic illness and preventive service. Community clinics and hospital-based clinics used more CMPs for asthma and diabetes than did Independent Practice Associations (IPAs), and profitable organizations used more CMPs for child and adolescent preventive services than did entities facing severe financial constraints. The use of CMPs by Medicaid HMOs and the presence of external (financial and nonfinancial) incentives for clinical performance were strongly associated with use of care management by provider organizations.

CONCLUSIONS

Physician and provider organizations heavily involved in California's Medicaid program are extensively engaged in preventive and chronic care management programs.