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Hussein AA, Shabir U, Mahmood AW, Harrington G, Khan M, Ahmad A, Howlader M, Colan N, Shah AA, Ghadersohi S, Jing Z, Xu B, Sule N, Kauffman E, Kuettel M, Guru K. The impact of NCCN-compliant multidisciplinary conference on the uptake of active surveillance among eligible patients with localized prostate cancer. Urol Oncol 2023; 41:483.e21-483.e26. [PMID: 37945390 DOI: 10.1016/j.urolonc.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION We sought to investigate the impact of National Comprehensive Cancer Network (NCCN)-compliant multidisciplinary conference on the uptake of active surveillance (AS) among eligible patients with prostate cancer. METHODS Retrospective review of our AS database was performed. Patients who are eligible for AS who sought a second opinion at a comprehensive cancer center (2010-2021) were presented to the multidisciplinary Localized Prostate Cancer Conference (LPCC) that includes urologists, radiation oncologists, pathologists, and patient advocates. Cochrane Armitage test was used to examine trends over time. Multivariable regression models were fit to evaluate variables associated with the receipt of AS. RESULTS Seven hundred twelve patients were identified (19% NCCN very low risk, 32% low risk, and 49% intermediate favorable risk). 43% were recommended AS as the preferred option by the community compared to 68% by LPCC, and 65% elected AS. Recommending AS significantly increased between 2010 and 2021 by the community (from 26% to 57%) and by LPCC (from 52% to 82%), while the proportion of men who received AS increased from 47% to 80% during the same period (P < 0.0001 for all). More recent LPCC era 2017 to 2021 (OR 12.31, 95% CI, 5.60-27.03, P < 0.0001), African American race (OR 0.42, 95% CI, 0.18-0.96, P = 0.04), positive cores at biopsy (OR 0.96, 95% CI, 0.94-0.97, P < 0.0001), age (OR 1.14, 95% CI, 1.10-1.18, P < 0.0001), NCCN low risk (OR 0.25, 95% CI, 0.08-0.81, P = 0.02) and NCCN intermediate favorable risk (OR 0.03, 95% CI, 0.01-0.09, P < 0.0001) were associated with receipt of AS. CONCLUSION AS recommendation increased significantly over time by community urologists and to a higher extent by NCCN-compliant multidisciplinary conference. The Uptake of AS significantly increased within the same period. More recent LPCC era 2017 to 2021, African American race, the proportion of positive cores at biopsy, age, and NCCN risk were the main determinants of receipt of AS.
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Affiliation(s)
- Ahmed A Hussein
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Usma Shabir
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Abdul Wasay Mahmood
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Grace Harrington
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Mohammad Khan
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ali Ahmad
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Muhsinah Howlader
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Nicholas Colan
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ayat A Shah
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Sarah Ghadersohi
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Zhe Jing
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Bo Xu
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Nobert Sule
- Department of Pathology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Eric Kauffman
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Michael Kuettel
- Department of Radiation Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Khurshid Guru
- Department of Urology, Roswell Park Comprehensive Cancer Center, Buffalo, NY.
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Spangler L, Yu O, Loggers E, Boudreau DM. Bone mineral density screening among women with a history of breast cancer treated with aromatase inhibitors. J Womens Health (Larchmt) 2013; 22:132-40. [PMID: 23362883 DOI: 10.1089/jwh.2012.3687] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Understanding adherence to bone mineral density (BMD) screening after breast cancer (BC) treatment with aromatase inhibitors (AI) is an important first step in preventing or treating BC-related osteoporosis. METHODS This retrospective cohort study assessed receipt and adherence to BMD screening among 342 women diagnosed with BC who were at high risk for osteoporosis after BC treatment with AI between 2004 and 2007. Nonadherence to baseline and annual BMD screening (recommended by 2003 American Society of Clinical Oncology Guidelines) was assessed using descriptive statistics and Poisson regression models accounting for length of AI use and follow-up. RESULTS In the year before AI initiation, 16% of women received BMD screening. Fifty-six percent had no BMD screening in the 14 months after a minimum of 9 months of continuous AI use, and 75% and 66% failed to have BMD screens during the second (14.1-26 month) and third (26.1-38 month) annual time periods after continuous AI use for at least 23 and 35 months, respectively. Overall, 24% had no BMD screening after 35 months of continuous AI use. Statistically significant predictors of nonadherence included predominant exemestane use, BMD screening before AI initiation, and diabetes mellitus history. Postcollege education, geographic region of primary care clinic, and never smoking were associated with a reduced risk of nonadherence. CONCLUSIONS A significant proportion of breast cancer patients treated with AI did not receive guideline-recommended BMD screening. Findings should raise awareness of the importance of BMD screening and targeting women at increased risk of screening nonadherence.
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Jorm LR, Shepherd LC, Rogers KD, Blyth FM. Smoking and use of primary care services: findings from a population-based cohort study linked with administrative claims data. BMC Health Serv Res 2012; 12:263. [PMID: 22900643 PMCID: PMC3502263 DOI: 10.1186/1472-6963-12-263] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2012] [Accepted: 08/12/2012] [Indexed: 11/29/2022] Open
Abstract
Background Available evidence suggests that smokers have a lower propensity than others to use primary care services. But previous studies have incorporated only limited adjustment for confounding and mediating factors such as income, access to services and health status. We used data from a large prospective cohort study (the 45 and Up Study), linked to administrative claims data, to quantify the relationship between smoking status and use of primary care services, including specific preventive services, in a contemporary Australian population. Methods Baseline questionnaire data from the 45 and Up Study were linked to administrative claims (Medicare) data for the 12-month period following study entry. The main outcome measures were Medicare benefit claimed for unreferred services, out-of-pocket costs (OOPC) paid, and claims for specific preventive services (immunisations, health assessments, chronic disease management services, PSA tests and Pap smears). Rate ratios with 95% confidence intervals were estimated using a hierarchical series of models, adjusted for predisposing, access- and health-related factors. Separate hurdle (two part) regression models were constructed for Medicare benefit and OOPC. Poisson models with robust error variance were used to model use of each specific preventive service. Results Participants included 254,382 people aged 45 years and over of whom 7.3% were current smokers. After adjustment for predisposing, access- and health-related factors, current smokers were very slightly less likely to have claimed Medicare benefit than never smokers. Among those who claimed benefit, current smokers claimed similar total benefit, but recent quitters claimed significantly greater benefit, compared to never-smokers. Current smokers were around 10% less likely than never smokers to have paid any OOPC. Current smokers were 15-20% less likely than never smokers to use immunisations, Pap smears and prostate specific antigen tests. Conclusions Current smokers were less likely than others to use primary care services that incurred out of pocket costs, and specific preventive services. This was independent of a wide range of predisposing, access- and health-related factors, suggesting that smokers have a lower propensity to seek health care. Smokers may be missing out on preventive services from which they would differentially benefit.
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Affiliation(s)
- Louisa R Jorm
- Centre for Health Research, School of Medicine, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia.
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Visser BC, Ma Y, Zak Y, Poultsides GA, Norton JA, Rhoads KF. Failure to comply with NCCN guidelines for the management of pancreatic cancer compromises outcomes. HPB (Oxford) 2012; 14:539-47. [PMID: 22762402 PMCID: PMC3406351 DOI: 10.1111/j.1477-2574.2012.00496.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION There are little data available regarding compliance with the National Comprehensive Cancer Network (NCCN) guidelines. We investigated variation in the management of pancreatic cancer (PC) among large hospitals in California, USA, specifically to evaluate whether compliance with NCCN guidelines correlates with patient outcomes. METHODS The California Cancer Registry was used to identify patients treated for PC from 2001 to 2006. Only hospitals with ≥ 400 beds were included to limit evaluation to centres possessing resources to provide multimodality care (n= 50). Risk-adjusted multivariable models evaluated predictors of adherence to stage-specific NCCN guidelines for PC and mortality. RESULTS In all, 3706 patients were treated for PC in large hospitals during the study period. Compliance with NCCN guidelines was only 34.5%. Patients were less likely to get recommended therapy with advanced age and low socioeconomic status (SES). Using multilevel analysis, controlling for patient factors (including demographics and comorbidities), hospital factors (e.g. size, academic affiliation and case volume), compliance with NCCN guidelines was associated with a reduced risk of mortality [odds ratio (OR) for death 0.64 (0.53-0.77, P < 0.0001)]. CONCLUSIONS There is relatively poor overall compliance with the NCCN PC guidelines in California's large hospitals. Higher compliance rates are correlated with improved survival. Compliance is an important potential measure of the quality of care.
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Affiliation(s)
- Brendan C Visser
- Department of Surgery, Stanford University Medical Center, CA 94305-5641, USA.
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Hysong SJ, Teal CR, Khan MJ, Haidet P. Improving quality of care through improved audit and feedback. Implement Sci 2012; 7:45. [PMID: 22607640 PMCID: PMC3462705 DOI: 10.1186/1748-5908-7-45] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 04/30/2012] [Indexed: 11/12/2022] Open
Abstract
Background The Department of Veterans Affairs (VA) has led the industry in measuring facility performance as a critical element in improving quality of care, investing substantial resources to develop and maintain valid and cost-effective measures. The External Peer Review Program (EPRP) of the VA is the official data source for monitoring facility performance, used to prioritize the quality areas needing most attention. Facility performance measurement has significantly improved preventive and chronic care, as well as overall quality; however, much variability still exists in levels of performance across measures and facilities. Audit and feedback (A&F), an important component of effective performance measurement, can help reduce this variability and improve overall performance. Previous research suggests that VA Medical Centers (VAMCs) with high EPRP performance scores tend to use EPRP data as a feedback source. However, the manner in which EPRP data are used as a feedback source by individual providers as well as service line, facility, and network leadership is not well understood. An in-depth understanding of mental models, strategies, and specific feedback process characteristics adopted by high-performing facilities is thus urgently needed. This research compares how leaders of high, low, and moderately performing VAMCs use clinical performance data from the EPRP as a feedback tool to maintain and improve quality of care. Methods We will conduct a qualitative, grounded theory analysis of up to 64 interviews using a novel method of sampling primary care, facility, and Veterans Integrated Service Network (VISN) leadership at high-, moderate-, and low-performing facilities. We will analyze interviews for evidence of cross-facility differences in perceptions of performance data usefulness and strategies for disseminating performance data evaluating performance, with particular attention to timeliness, individualization, and punitiveness of feedback delivery. Discussion Most research examining feedback to improve provider and facility performance lacks a detailed understanding of the elements of effective feedback. This research will highlight the elements most commonly used at high-performing facilities and identify additional features of their successful feedback strategies not previously identified. Armed with this information, practices can implement more effective A&F interventions to improve quality of care.
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Affiliation(s)
- Sylvia J Hysong
- Houston VA Health Services Research & Development Center of Excellence, Michael E, DeBakey VA Medical Center, Houston, TX, USA.
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Passive monitoring versus active assessment of clinical performance: impact on measured quality of care. Med Care 2011; 49:883-90. [PMID: 21918399 DOI: 10.1097/mlr.0b013e318222a36c] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
CONTEXT Measurement of hospitals' clinical performance is becoming more ubiquitous in an effort to inform patient choices, payer reimbursement decisions, and quality improvement initiatives such as pay-for-performance. As more measures are developed, the intensity with which measures are monitored changes. Performance measures are often retired after a period of sustained performance and not monitored as actively as other measures where performance is more variable. The effect of actively versus passively monitoring performance on measured quality of care is not known. OBJECTIVE We compared the nature and rate of change in hospital outpatient clinical performance as a function of a measure's status (active vs. passive), and examined the mean time to stability of performance after changing status. We hypothesize that performance will be higher when measures are actively monitored than when they are passively monitored. DESIGN Longitudinal, hierarchical retrospective analyses of outpatient clinical performance measure data from Veterans Health Administration's External Peer Review Program from 2000 to 2008. SETTING One hundred thirty-three Veterans Health Administration Medical Centers throughout the United States and its associated territories. MAIN OUTCOME MEASURES Clinical performance on 17 measures covering 5 clinical areas common to ambulatory care: screening, immunization, chronic care after acute myocardial infarction, diabetes mellitus, and hypertension. RESULTS Contrary to expectations, we found that measure status (whether active or passive) did not significantly impact performance over time; time to stability of performance varied considerably by measure, and did not seem to covary with performance at the stability point (ie, performance scores for measures with short stability times were no higher or lower than scores for measures with longer stability times). CONCLUSIONS We found no significant "extinction" of performance after measures were retired, suggesting that other features of the health care system, such as organizational policies and procedures or other structural features, may be creating a "strong situation" and sustaining performance. Future research should aim to better understand the effects of monitoring performance using process-of-care measures and creating sustained high performance.
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Buetow S, Janes R, Steed R, Ihimaera L, Elley CR. Why don't some women return for cervical smears? A hermeneutic phenomenological investigation. Health Care Women Int 2008; 28:843-52. [PMID: 17907011 DOI: 10.1080/07399330701563251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
To enhance understanding of how having a cervical smear can lead some women not to keep up-to-date with this test, a hermeneutic (interpretative) phenomenological study was undertaken. Participants were six purposively selected New Zealand women -- predominantly Māori -- at least 6 months overdue for a follow-up cervical screen in the previous 6 years. Each woman gave an in-depth interview. Transcribed and analyzed via a general inductive approach, the interviews suggested that the smears can violate women's positive aloneness with their bodies, and magnify aloneness as a negative state. Overdueness for the test avoids these effects. To minimize such effects, primary health care needs to acknowledge and address these issues, for example by providing an opportunity to connect the aloneness to trusted others.
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Affiliation(s)
- Stephen Buetow
- Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand.
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Tabaei BP, Herman WH, Jabarin AF, Kim C. Does diabetes care compete with the provision of women's preventive care services? Diabetes Care 2005; 28:2644-9. [PMID: 16249533 DOI: 10.2337/diacare.28.11.2644] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Care for chronic diseases may compete with preventive health care. To test this hypothesis, we examined the association between diabetes-related processes of care and preventive care in women. RESEARCH DESIGN AND METHODS Using data from a prospective cohort study of diabetes care in managed care settings, we reviewed the care 540 diabetic women received from 355 primary care providers within 14 provider groups from one health plan. Of the 540 women, 278 were eligible to receive mammograms and 314 were eligible to receive Pap smears. Mammography performance was measured as at least one mammogram over a 2-year period and Pap performance was measured as at least one Pap smear over a 3-year period. To assess the association between diabetes-related processes of care and preventive services, we used hierarchical logistic regression models, accounted for clustering within provider groups, and adjusted for patient age, race, income and education level, diabetes treatment and duration, and health status, as well as physician age, sex, years of practice, and specialty. Diabetes-related processes of care were defined as dilated retinal examinations, urine microalbumin/protein testing, foot examinations, lipid and HbA(1c) testing, recommendations to take aspirin, and influenza vaccinations received over a 1-year period. RESULTS In this cohort, 73% of eligible women received mammograms and 56% received Pap smears. After adjustment of models, better diabetes-related processes of care, better health status, and non-Medicaid insurance were associated with mammography performance. Better diabetes-related processes of care, younger patient age, and any visit to a gynecologist were associated with Pap performance. CONCLUSIONS Better processes of diabetes care were associated with better women's preventive health care. Diabetes management did not compete with sex-specific screening.
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Affiliation(s)
- Bahman P Tabaei
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, MI, USA
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Franks P, Fiscella K, Beckett L, Zwanziger J, Mooney C, Gorthy S. Effects of patient and physician practice socioeconomic status on the health care of privately insured managed care patients. Med Care 2003; 41:842-52. [PMID: 12835608 DOI: 10.1097/00005650-200307000-00008] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research shows that patient socioeconomic status (SES) affects health care, but little is known about the relative effects of patient and physician practice SES among privately insured patients. OBJECTIVE To examine the effects of patient and physician practice SES on prevention, disease management, utilization, and cost expenditures. DESIGN Cross-sectional analyses of claims data. SUBJECTS Primary care physicians (568) and their adult managed care organization patients (437,743) in the Rochester, New York, area. MEASURES Pap smears, mammograms, glycohemoglobins, and eye examinations for diabetics, physician visits, referrals, hospitalizations, costs standardized expenditures (diagnostic testing, office visits, and total), patient zip code-based SES, and physician practice SES (mean SES of patients in practice). RESULTS After adjustment, lower SES patients had lower compliance with Pap smears, mammograms, and diabetic eye exams, and were less likely to have a referral or make any office visit, but were more likely to be hospitalized, and generated higher testing standardized expenditures. Lower physician practice SES was associated with lower adjusted Pap, mammogram, and glycohemoglobin compliance, lower office visit standardized expenditures, but higher diagnostic testing and total standardized expenditures. Patient SES effects were stronger for mammography, whereas physician practice SES effects were stronger for diagnostic testing costs. For the utilization indicators, the SES effects on utilization exhibited a linear gradient, whereas there was a threshold effect for costs. CONCLUSIONS Patient and practice SES are independently associated with care among privately insured patients. These effects are not confined to the poorest patients but span the entire socioeconomic spectrum. Interventions to address these disparities need to be broad-based, but should also address the needs of practices with predominantly lower SES patients.
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Affiliation(s)
- Peter Franks
- Department of Family and Community Medicine, Center for Health Services Research in Primary Care, University of California, Davis 95817, USA.
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Ell K, Vourlekis B, Muderspach L, Nissly J, Padgett D, Pineda D, Sarabia O, Lee PJ. Abnormal cervical screen follow-up among low-income Latinas: Project SAFe. JOURNAL OF WOMEN'S HEALTH & GENDER-BASED MEDICINE 2002; 11:639-51. [PMID: 12396896 DOI: 10.1089/152460902760360586] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cervical cancer incidence and mortality rates are dramatically higher among low-income women than in the general population, in part due to poor adherence to recommended diagnostic follow-up after an index Pap test. This report describes a pilot study of the Screening Adherence Follow-Up Program (SAFe), an individualized, structured case management program designed to assess for and intervene in response to a variety of potential personal and systems barriers to follow-up adherence. Interventions included health education, counseling, and systems navigation. METHODS A clinical decision-making algorithm was used to determine service intensity and level of intervention. Services were provided to 196 low-income women, predominantly Latinas, who had either a low-grade or high-grade squamous intraepithelial lesion (LGSIL or HGSIL) abnormal Pap result. Adherence rates to at least one follow-up appointment after enrollment and baseline intervention were 83% following LGSIL and 93% for HGSIL. RESULTS Over 1 year post-enrollment, 41% of women with LGSIL were fully adherent, with 42% partially adherent; 61% of women with HGSIL were fully adherent, with 32% partially adherent. In a comparison group of 369 nonenrollees (women who refused participation or could not be located for consent), adherence rates were 58% for LGSIL and 67% for HGSIL. A survey among a random sample of women served indicated that 93% were "mostly" or "very" satisfied, overall, with SAFe services. CONCLUSIONS The intervention team--a peer counselor and a master's degreed social worker--addressed multiple psychosocial and systems navigation problems to reduce potential barriers to adherence, including knowledge, attitudinal, psychosocial, psychological distress, systems communication, and resource access problems. SAFe appears highly acceptable to women and may significantly enhance medical care management following an abnormal cervical screen for a carefully targeted group of women at risk for suboptimal follow-up adherence.
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Affiliation(s)
- Kathleen Ell
- School of Social Work, University of Southern California, MRF 214 (MC 0411), Los Angeles, CA 90089-0411, USA
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Franks P, Fiscella K. Effect of patient socioeconomic status on physician profiles for prevention, disease management, and diagnostic testing costs. Med Care 2002; 40:717-24. [PMID: 12187185 DOI: 10.1097/00005650-200208000-00011] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research shows patient socioeconomic status (SES) affects physician profiles for health status and satisfaction, but effects on other aspects of care are not known. OBJECTIVE To examine the effect of patient SES on physician profiles for preventive care, disease management, and diagnostic testing costs. RESEARCH DESIGN Cross-sectional analysis of a managed care claims data. SUBJECTS Five hundred sixty-eight physicians and 600,618 patients. MEASURES Patient age, gender, case-mix, and SES based on zip code, likelihood of having a Papanicolaou smear, mammogram, for diabetics having had a glycosylated hemoglobin, diabetic eye exam, and diagnostic testing costs. RESULTS For each performance indicator, except glycosylated hemoglobin, there was a statistically significant effect of adjusting for patient SES. For diabetic eye checks, mammograms and Papanicolaou tests respectively, 5%, 16%, and 21% of physicians who were outliers (in the top or bottom 5% of rankings) were no longer outliers after socioeconomic adjustment. For all performance measures the change in physician ranking was strongly correlated with the mean practice SES. CONCLUSIONS Patient SES, as measured by zip code, appreciably affects physician profiles for preventive care and diabetes management. Monitoring patient SES using patient zip codes could be used to target resources to improve outcomes for higher risk patients.
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Affiliation(s)
- Peter Franks
- Department of Family and Community Medicine, University of California School of Medicine, Davis, CA, USA
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Goldberg HI, Neighbor WE, Hirsch IB, Cheadle AD, Ramsey SD, Gore E. Evidence-based management: using serial firm trials to improve diabetes care quality. THE JOINT COMMISSION JOURNAL ON QUALITY IMPROVEMENT 2002; 28:155-66. [PMID: 11942259 DOI: 10.1016/s1070-3241(02)28016-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.
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