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Miller DR, Reisman JI, McDannold SE, Kleinberg F, Gillespie C, Zogas A, Ndiwane N, Ourth HL, Morreale AP, Tran M, McCullough MB. Clinical pharmacist practitioners on primary care teams play an important role in caring for complex patients with diabetes. Am J Health Syst Pharm 2023; 80:1637-1649. [PMID: 37566141 DOI: 10.1093/ajhp/zxad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Indexed: 08/12/2023] Open
Abstract
PURPOSE To evaluate whether clinical pharmacist practitioners (CPPs) are being utilized to care for patients with complex medication regimens and multiple chronic illnesses, we compared the clinical complexity of diabetes patients referred to CPPs in team primary care and those in care by other team providers (OTPs). METHODS In this cross-sectional comparison of patients with diabetes in the US Department of Veterans Affairs (VA) healthcare system in the 2017-2019 period, patient complexity was based on clinical factors likely to indicate need for more time and resources in medication and disease state management. These factors include insulin prescriptions; use of 3 or more other diabetes medication classes; use of 6 or more other medication classes; 5 or more vascular complications; metabolic complications; 8 or more other complex chronic conditions; chronic kidney disease stage 3b or higher; glycated hemoglobin level of ≥10%; and medication regime nonadherence. RESULTS Patients with diabetes referred to one of 110 CPPs for care (n = 12,728) scored substantially higher (P < 0.001) than patients with diabetes in care with one of 544 OTPs (n = 81,183) on every complexity measure, even after adjustment for age, sex, race, and marital status. Based on composite summary scores, the likelihood of complexity was 3.42 (interquartile range, 3.25-3.60) times higher for those in ongoing CPP care (ie, those with 2 or more visits) versus OTP care. Patients in CPP care also were, on average, younger, more obese, and had more prior outpatient visits and hospital stays. CONCLUSION The greater complexity of patients with diabetes seen by CPPs in primary care suggests that CPPs are providing valuable services in comprehensive medication and disease management of complex patients.
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Affiliation(s)
- Donald R Miller
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA, USA
| | - Joel I Reisman
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Sarah E McDannold
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Felicia Kleinberg
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Chris Gillespie
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Anna Zogas
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Boston, MA, USA
| | - Ndindam Ndiwane
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Heather L Ourth
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Anthony P Morreale
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Michael Tran
- Pharmacy Benefits Management Services, National Clinical Pharmacy Practice Office, US Department of Veterans Affairs, Washington, DC, USA
| | - Megan B McCullough
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
- Zuckerberg School of Health Sciences, Department of Public Health, University of Massachusetts, Lowell, MA, USA
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Nichols GA, Raebel MA, Dyer W, Schmittdiel JA. The Effect of Age and Comorbidities on the Association Between the Medicare STAR Oral Antihyperglycemic Adherence Metric and Glycemic Control. J Manag Care Spec Pharm 2018; 24:856-861. [PMID: 30156449 PMCID: PMC10398005 DOI: 10.18553/jmcp.2018.24.9.856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The Medicare STAR program for Medicare Advantage Plans that include drug benefits provides monetary incentives for health plans to achieve good adherence to oral antihyperglycemic (OAH) agents but does not account for differential case mix that could affect the ability of health plans to achieve the required quality metrics. OBJECTIVE To determine whether OAH adherence varies by age and comorbidities among patients aged 65 years or older and the extent to which adherence affects glycemic control across age and comorbidity strata. METHODS We studied 54,480 patients with diabetes aged > 65 years from the Colorado, Northwest, and Northern California regions of Kaiser Permanente who received OAH agents but not insulin in 2010. We calculated adherence using the proportion of days covered (PDC) method. Per the STAR program, hemoglobin A1c < 8% defined good glycemic control. We also defined poor control as A1c > 9%. We used modified Poisson regression to identify predictors of adherence and to determine its effects on A1c across age and comorbidity strata, adjusting for sociodemographics and medication-related variables. RESULTS The risk of being adherent to OAH declined moderately with an increasing number of comorbidities (risk ratio [RR] = 0.99, 95% CI = 0.98-1.00 for 1 comorbidity and RR = 0.90, 95% CI = 0.88-0.91 for 4 or more comorbidities). Adherence to OAH agents was associated with a 0%-3% increased risk of A1c < 8% across age and comorbidity categories, as well as a large decreased risk (RR = 0.55-0.73) of A1c > 9% for patients aged < 80 years or with < 3 comorbidities. CONCLUSIONS Among patients with diabetes aged > 65 years, having multiple comorbidities affects adherence. Adherence reduces the risk of poor A1c control among patients aged 65-79 years or with 2 or fewer comorbidities. Our results suggest that health plan case mix minimally influenced the Medicare STAR OAH adherence metric, but it may affect glycemic control quality measures, especially if a HEDIS-like measure of poor control were adopted. DISCLOSURES This study was supported by grant number 1R21DK103146-01A1 from the National Institute of Diabetes and Digestive and Kidney Disorders. Nichols currently receives grant funding from Boehringer-Ingelheim, Sanofi, Amarin Pharma, and Janssen Pharmaceuticals for other unrelated research projects. The other authors declare no conflicts of interest. This study was presented at the American Diabetes Association's 77th Scientific Sessions; June 9-13, 2017; San Diego, CA.
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Affiliation(s)
- Gregory A Nichols
- 1 Kaiser Permanente Northwest Center for Health Research, Portland, Oregon
| | - Marsha A Raebel
- 2 Kaiser Permanente Colorado Institute for Health Research, Denver
| | - Wendy Dyer
- 3 Kaiser Permanente Northern California Division of Research, Oakland
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Danek E, Earnest A, Wischer N, Andrikopoulos S, Pease A, Nanayakkara N, Zoungas S. Risk-adjustment of diabetes health outcomes improves the accuracy of performance benchmarking. Sci Rep 2018; 8:10261. [PMID: 29980691 PMCID: PMC6035186 DOI: 10.1038/s41598-018-28101-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 05/31/2018] [Indexed: 12/20/2022] Open
Abstract
Benchmarking clinical performance by comparing diabetes health outcomes across healthcare providers drives quality improvement. Non-care related patient risk factors are likely to confound clinical performance, but few studies have tested this. This cross-sectional study is the first Australian investigation to analyse the effect of risk-adjustment for non-care related patient factors on benchmarking. Data from 4,670 patients with type 2 (n = 3,496) or type 1 (n = 1,174) were analysed across 49 diabetes centres. Diabetes health outcomes (HbA1c levels, LDL-cholesterol levels, systolic blood pressure and rates of severe hypoglycaemia) were risk-adjusted for non-care related patient factors using multivariate stepwise linear and logistic regression models. Unadjusted and risk-adjusted funnel plots were constructed for each outcome to identify low-performing and high-performing outliers. Unadjusted funnel plots identified 27 low-performing outliers and 15 high-performing outliers across all diabetes health outcomes. After risk-adjustment, 22 (81%) low-performing outliers and 13 (87%) high-performing outliers became inliers. Additionally, one inlier became a low-performing outlier. Risk-adjustment of diabetes health outcomes significantly reduced false positives and false negatives for outlier performance, hence providing more accurate information to guide quality improvement activity.
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Affiliation(s)
- Eleanor Danek
- Monash University, School of Public Health and Preventive Medicine, Melbourne, 3004, Australia
| | - Arul Earnest
- Monash University, Biostatistics Unit and Registry Unit in the Department of Epidemiology and Preventive Medicine, Melbourne, 3004, Australia
| | - Natalie Wischer
- Monash University, School of Public Health and Preventive Medicine, Melbourne, 3004, Australia
| | - Sofianos Andrikopoulos
- University of Melbourne, Islet Biology and Metabolism Research Group in the Department of Medicine, Melbourne Biostatistics Unit in the Department of Epidemiology and Preventive Medicine, Melbourne, 3010, Australia
| | - Anthony Pease
- Monash University, Division of Metabolism, Ageing and Genomics in the Department of Epidemiology and Preventive Medicine, Melbourne, 3004, Australia
| | - Natalie Nanayakkara
- Monash University, School of Public Health and Preventive Medicine, Melbourne, 3004, Australia
| | - Sophia Zoungas
- Monash University, Diabetes, Vascular Health and Ageing, Division of Metabolism, Ageing and Genomics, School of Public Health and Preventive Medicine, Melbourne, 3004, Australia.
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Soley-Bori M, Benzer JK, Burgess JF. Longitudinal Analysis of Quality of Diabetes Care and Relational Climate in Primary Care. Health Serv Res 2017; 53:1042-1064. [PMID: 28294310 DOI: 10.1111/1475-6773.12675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To assess the influence of relational climate on quality of diabetes care. DATA SOURCES/STUDY SETTING The study was conducted at the Department of Veterans Affairs (VA). The VA All Employee Survey (AES) was used to measure relational climate. Patient and facility characteristics were gathered from VA administrative datasets. STUDY DESIGN Multilevel panel data (2008-2012) with patients nested into clinics. DATA COLLECTION/EXTRACTION METHODS Diabetic patients were identified using ICD-9 codes and assigned to the clinic with the highest frequency of primary care visits. Multiple quality indicators were used, including an all-or-none process measure capturing guideline compliance, the actual number of tests and procedures, and three intermediate continuous outcomes (cholesterol, glycated hemoglobin, and blood pressure). PRINCIPAL FINDINGS The study sample included 327,805 patients, 212 primary care clinics, and 101 parent facilities in 2010. Across all study years, there were 1,568,180 observations. Clinics with the highest relational climate were 25 percent more likely to provide guideline-compliant care than those with the lowest relational climate (OR for a 1-unit increase: 1.02, p-value <.001). Among insulin-dependent diabetic veterans, this effect was twice as large. Contrary to that expected, relational climate did not influence intermediate outcomes. CONCLUSIONS Relational climate is positively associated with tests and procedures provision, but not with intermediate outcomes of diabetes care.
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Affiliation(s)
- Marina Soley-Bori
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA.,Department of Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA.,Health Care Financing and Payment Program (HCFP), RTI International, Waltham, MA
| | - Justin K Benzer
- Department of Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA.,Department of Veterans Affairs Central Texas Healthcare System, VISN 17 Center of Excellence for Research on Returning Veterans, Waco, TX.,Department of Health Policy and Management, Texas A&M University School of Public Health, College Station, TX
| | - James F Burgess
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA.,Department of Veterans Affairs Boston Healthcare System, Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA
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Bailey S, O’Malley JP, Gold R, Heintzman J, Likumahuwa S, DeVoe JE. Diabetes care quality is highly correlated with patient panel characteristics. J Am Board Fam Med 2013; 26:669-79. [PMID: 24204063 PMCID: PMC3922763 DOI: 10.3122/jabfm.2013.06.130018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs). METHODS Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined. RESULTS Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators. CONCLUSIONS Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.
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Affiliation(s)
- Steffani Bailey
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Jean P. O’Malley
- Oregon Health & Science University, Department of Public Health and Preventive Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Rachel Gold
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227
| | - John Heintzman
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Sonja Likumahuwa
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Jennifer E. DeVoe
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239, Ph: 503-494-8936
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Piette JD, Valenstein M, Himle J, Duffy S, Torres T, Vogel M, Richardson C. Clinical complexity and the effectiveness of an intervention for depressed diabetes patients. Chronic Illn 2011; 7:267-78. [PMID: 21840915 PMCID: PMC3983967 DOI: 10.1177/1742395311409259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES In a trial completed in 2010, US patients with diabetes and depression were randomized to usual care or telephone cognitive behavioural therapy that emphasized physical activity. Twelve-month intervention effects were observed for blood pressure, depression, and pedometer-measured step-counts. This study examined variation in intervention effects across patient subgroups defined by a measure of clinical complexity. METHODS Three groups of patients were identified at baseline using the Vector Model of Complexity that recognizes socioeconomic, biological, behavioural, and other determinants of treatment response. Complexity-by-intervention interactions were examined using regression models. RESULTS Intervention effects for blood pressure, depression, and step-counts differed across complexity levels (each p < 0.01). Effects on Beck Depression Inventory scores were greater in the low-complexity group (-8.8) than in the medium- (-3.2) or high-complexity groups (-2.7). Physical activity effects also were greatest in the low-complexity group (increase of 1498 steps per day). In contrast, systolic blood pressure effects were greater among intervention patients with high complexity (-8.5 mmHg). CONCLUSIONS This intervention had varying impacts on physical and mental health depending on patients' clinical complexity. Physical activity and depressive symptom gains may be more likely among less complex patients, although more complex patients may achieve cardiovascular benefits through decreased blood pressures.
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Affiliation(s)
- John D Piette
- Ann Arbor VA Healthcare System, HSR&D Center for Clinical Management Research, Ann Arbor, MI, USA.
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Salanitro AH, Safford MM, Houston TK, Williams JH, Ovalle F, Payne-Foster P, Allison JJ, Estrada CA. Patient complexity and diabetes quality of care in rural settings. J Natl Med Assoc 2011; 103:234-40. [PMID: 21671526 DOI: 10.1016/s0027-9684(15)30297-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States. BASIC PROCEDURES Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice's proportion of patients having controlled diabetes (hemoglobin A1c<or=7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories. MAIN FINDINGS Rural primary care practices (n=135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p<.05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (kappa=0.47; 95% confidence interval, 0.32-0.56; p<001). PRINCIPAL CONCLUSIONS Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.
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Affiliation(s)
- Amanda H Salanitro
- VA Tennessee Valley Geriatric Research, Education, and Clinical Center and Section of Hospital Medicine at Vanderbilt University, Room A-414, 1310 24th Ave S, Nashville, TN 37212, USA.
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Wade D. Complexity, case-mix and rehabilitation: the importance of a holistic model of illness. Clin Rehabil 2011; 25:387-95. [DOI: 10.1177/0269215511400282] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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