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Staloff J, Gunnink E, Rojas J, Wong ES, Nelson K, Reddy A. Identifying Patterns of Primary Care In-Person and Telemedicine Use in the Veterans Health Administration: A Latent Class Analysis. J Gen Intern Med 2024:10.1007/s11606-024-08751-5. [PMID: 38619738 DOI: 10.1007/s11606-024-08751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 03/29/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND The Veterans Health Administration increased synchronous telemedicine (video and telephone visits) in primary care in response to the COVID-19 pandemic. OBJECTIVE Our objective was to determine veteran use patterns of in-person and telemedicine primary care when all modalities were available. DESIGN A retrospective cohort analysis. We performed a latent class analysis of primary care visits over a 1-year period to identify veteran subgroup (i.e., class) membership based on amount of primary care use and modality used. Then, we used multinomial logistic regression with a categorical outcome to identify patient characteristics associated with class identification. PARTICIPANTS A random national sample consisting of 564,580 primary care empaneled veterans in June 2021. MAIN MEASURES Latent class membership. KEY RESULTS We identified three latent classes: those with few primary care visits that were predominantly telephone-based (45%), intermediate number of visits of all modalities (50%), and many visits of all modalities (5%). In an adjusted model, characteristics associated with the "few" visits class, compared to the intermediate class, were older age, male sex, White race, further driving distance to primary care, higher Gagne, optimal internet speed, and unmarried status (OR 1.002, 1.52, 1.13, 1.004, 1.04, 1.05, 1.06, respectively; p < .05). Characteristics associated with membership in the "many" visits class, compared to the intermediate class, were Hispanic race, higher JEN Frailty Index and Gagne (OR 1.12, 1.11, 1.02, respectively; p < .05), and higher comorbidity by Care Assessment Need score quartile (Q2 1.73, Q3 2.80, Q4 4.12; p < 0.05). CONCLUSIONS Veterans accessing primary care in-person or via telemedicine do so primarily in three ways: (1) few visits, predominantly telephone; (2) intermediate visits, all modalities, (3) many visits, all modalities. We found no groups of veterans receiving a majority of primary care through video.
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Affiliation(s)
- Jonathan Staloff
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Department of Family Medicine, University of Washington, Seattle, WA, USA.
| | - Eric Gunnink
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Jorge Rojas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
| | - Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
| | - Karin Nelson
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Ashok Reddy
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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Rajan SS, Sarvepalli S, Wei L, Meyer AND, Murphy DR, Choi DT, Singh H. Medical Home Implementation and Follow-Up of Cancer-Related Abnormal Test Results in the Veterans Health Administration. JAMA Netw Open 2024; 7:e240087. [PMID: 38483392 PMCID: PMC10940951 DOI: 10.1001/jamanetworkopen.2024.0087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 12/18/2023] [Indexed: 03/17/2024] Open
Abstract
Importance Lack of timely follow-up of cancer-related abnormal test results can lead to delayed or missed diagnoses, adverse cancer outcomes, and substantial cost burden for patients. Care delivery models, such as the Veterans Affairs' (VA) Patient-Aligned Care Team (PACT), which aim to improve patient-centered care coordination, could potentially also improve timely follow-up of abnormal test results. PACT was implemented nationally in the VA between 2010 and 2012. Objective To evaluate the long-term association between PACT implementation and timely follow-up of abnormal test results related to the diagnosis of 5 different cancers. Design, Setting, and Participants This multiyear retrospective cohort study used 14 years of VA data (2006-2019), which were analyzed using panel data-based random-effects linear regressions. The setting included all VA clinics and facilities. The participants were adult patients who underwent diagnostic testing related to 5 different cancers and had abnormal test results. Data extraction and statistical analyses were performed from September 2021 to December 2023. Exposure Calendar years denoting preperiods and postperiods of PACT implementation, and the PACT Implementation Progress Index Score denoting the extent of implementation in each VA clinic and facility. Main Outcome and Measure Percentage of potentially missed timely follow-ups of abnormal test results. Results This study analyzed 6 data sets representing 5 different types of cancers. During the initial years of PACT implementation (2010 to 2013), percentage of potentially missed timely follow-ups decreased between 3 to 7 percentage points for urinalysis suggestive of bladder cancer, 12 to 14 percentage points for mammograms suggestive of breast cancer, 19 to 22 percentage points for fecal tests suggestive of colorectal cancer, and 6 to 13 percentage points for iron deficiency anemia laboratory tests suggestive of colorectal cancer, with no statistically significant changes for α-fetoprotien tests and lung cancer imaging. However, these beneficial reductions were not sustained over time. Better PACT implementation scores were associated with a decrease in potentially missed timely follow-up percentages for urinalysis (0.3-percentage point reduction [95% CI, -0.6 to -0.1] with 1-point increase in the score), and laboratory tests suggestive of iron deficiency anemia (0.5-percentage point reduction [95% CI,-0.8 to -0.2] with 1-point increase in the score). Conclusions and Relevance This cohort study found that implementation of PACT in the VA was associated with a potential short-term improvement in the quality of follow-up for certain test results. Additional multifaceted sustained interventions to reduce missed test results are required to prevent care delays.
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Affiliation(s)
- Suja S. Rajan
- Department of Management, Policy & Community Health, School of Public Health, The University of Texas Health Science Center at Houston
| | | | - Li Wei
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Ashley N. D. Meyer
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Daniel R. Murphy
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Debra T. Choi
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Wheat CL, Gunnink EJ, Rojas J, Shah A, Nelson KM, Wong ES, Gray KE, Stockdale SE, Rosland AM, Chang ET, Reddy A. Changes in Primary Care Quality Associated With Implementation of the Veterans Health Administration Preventive Health Inventory. JAMA Netw Open 2023; 6:e238525. [PMID: 37067799 PMCID: PMC10111181 DOI: 10.1001/jamanetworkopen.2023.8525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 02/25/2023] [Indexed: 04/18/2023] Open
Abstract
Importance The COVID-19 pandemic caused significant disruptions in primary care delivery. The Veterans Health Administration (VHA) launched the Preventive Health Inventory (PHI) program-a multicomponent care management intervention, including a clinical dashboard and templated electronic health record note-to support primary care in delivering chronic disease care and preventive care that had been delayed by the pandemic. Objectives To describe patient, clinician, and clinic correlates of PHI use in primary care clinics and to examine associations between PHI adoption and clinical quality measures. Design, Setting, and Participants This quality improvement study used VHA administrative data from February 1, 2021, through February 28, 2022, from a national cohort of 216 VHA primary care clinics that have implemented the PHI. Participants comprised 829 527 veterans enrolled in primary care in clinics with the highest and lowest decile of PHI use as of February 2021. Exposure Templated electronic health record note documenting use of the PHI. Main Outcomes and Measures Diabetes and blood pressure clinical quality measures were the primary outcomes. Interrupted time series models were applied to estimate changes in diabetes and hypertension quality measures associated with PHI implementation. Low vs high PHI use was stratified at the facility level to measure whether systematic differences in uptake were associated with quality. Results A total of 216 primary clinics caring for 829 527 unique veterans (mean [SD] age, 64.1 [16.9] years; 755 158 of 829 527 [91%] were men) formed the study cohort. Use of the PHI varied considerably across clinics. The clinics in the highest decile of PHI use completed a mean (SD) of 32 997.4 (14 019.3) notes in the electronic health record per 100 000 veterans compared with 56.5 (35.3) notes per 100 000 veterans at the clinics in the lowest decile of use (P < .001). Compared with the clinics with the lowest use of the PHI, clinics with the highest use had a larger mean (SD) clinic size (12 072 [7895] patients vs 5713 [5825] patients; P < .001), were more likely to be urban (91% vs 57%; P < .001), and served more non-Hispanic Black veterans (16% vs 5%; P < .001) and Hispanic veterans (14% vs 4%; P < .001). Staffing did not differ meaningfully between high- and low-use clinics (mean [SD] ratio of full-time equivalent staff to clinician, 3.4 [1.2] vs 3.4 [0.8], respectively; P < .001). After PHI implementation, compared with the clinics with the lowest use, those with the highest use had fewer veterans with a hemoglobin A1c greater than 9% or missing (mean [SD], 6577 [3216] per 100 000 veterans at low-use clinics; 9928 [4236] per 100 000 veterans at high-use clinics), more veterans with an annual hemoglobin A1c measurement (mean [SD], 13 181 [5625] per 100 000 veterans at high-use clinics; 8307 [3539] per 100 000 veterans at low-use clinics), and more veterans with adequate blood pressure control (mean [SD], 20 582 [12 201] per 100 000 veterans at high-use clinics; 12 276 [6850] per 100 000 veterans at low-use clinics). Conclusions and Relevance This quality improvement study of the implementation of the VHA PHI suggests that higher use of a multicomponent care management intervention was associated with improved quality-of-care metrics. The study also found significant variation in PHI uptake, with higher uptake associated with clinics with more racial and ethnic diversity and larger, urban clinic sites.
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Affiliation(s)
- Chelle L. Wheat
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Eric J. Gunnink
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Jorge Rojas
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Ami Shah
- Office of Primary Care, Veterans Health Affairs, Washington, DC
| | - Karin M. Nelson
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Edwin S. Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Kristen E. Gray
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Susan E. Stockdale
- Department of Psychiatry and Biobehavioral Medicine, David Geffen School of Medicine, University of California at Los Angeles
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Ann-Marie Rosland
- Department of Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Evelyn T. Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, University of California at Los Angeles
- Division of General Internal Medicine, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Ashok Reddy
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
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Swankoski KE, Reddy A, Grembowski D, Chang ET, Wong ES. Intensive care management for high-risk veterans in a patient-centered medical home - do some veterans benefit more than others? HEALTHCARE (AMSTERDAM, NETHERLANDS) 2023; 11:100677. [PMID: 36764053 DOI: 10.1016/j.hjdsi.2023.100677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 11/30/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Primary care intensive management programs utilize interdisciplinary care teams to comprehensively meet the complex care needs of patients at high risk for hospitalization. The mixed evidence on the effectiveness of these programs focuses on average treatment effects that may mask heterogeneous treatment effects (HTEs) among subgroups of patients. We test for HTEs by patients' demographic, economic, and social characteristics. METHODS Retrospective analysis of a VA randomized quality improvement trial. 3995 primary care patients at high risk for hospitalization were randomized to primary care intensive management (n = 1761) or usual primary care (n = 1731). We estimated HTEs on ED and hospital utilization one year after randomization using model-based recursive partitioning and a pre-versus post-with control group framework. Splitting variables included administratively collected demographic characteristics, travel distance, copay exemption, risk score for future hospitalizations, history of hospital discharge against medical advice, homelessness, and multiple residence ZIP codes. RESULTS There were no average or heterogeneous treatment effects of intensive management one year after enrollment. The recursive partitioning algorithm identified variation in effects by risk score, homelessness, and whether the patient had multiple residences in a year. Within each distinct subgroup, the effect of intensive management was not statistically significant. CONCLUSIONS Primary care intensive management did not affect acute care use of high-risk patients on average or differentially for patients defined by various demographic, economic, and social characteristics. IMPLICATIONS Reducing acute care use for high-risk patients is complex, and more work is required to identify patients positioned to benefit from intensive management programs.
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Affiliation(s)
- Kaylyn E Swankoski
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value- Driven Care, Seattle, WA, USA.
| | - Ashok Reddy
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value- Driven Care, Seattle, WA, USA; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - David Grembowski
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
| | - Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, USA; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Edwin S Wong
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA; VA Puget Sound Health Care System, Center of Innovation for Veteran-Centered and Value- Driven Care, Seattle, WA, USA
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5
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Oh A, Scott JY, Chow A, Jiang H, Dismuke-Greer CE, Gujral K, Yoon J. Rural and urban differences in the implementation of Virtual Integrated Patient-Aligned Care Teams. J Rural Health 2023; 39:272-278. [PMID: 35611882 DOI: 10.1111/jrh.12676] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE Workforce shortages contribute to geographic disparities in accessing primary care services. An innovative, clinic-to-clinic videoconferencing telehealth program in the Veterans Health Administration (VHA) called the Virtual Integrated Patient-Aligned Care Teams (V-IMPACT) was designed to increase veterans' access to primary care and relieve workforce shortages in VA primary care clinics, including in many rural areas. This paper describes trends in clinic sites and veteran uptake of the V-IMPACT program, a model that delivered remote, team-based primary care services, from fiscal years (FY)2013-2018. METHODS This observational study used VHA administrative data to compare program uptake, measured by the program penetration rate (percent of patients using V-IMPACT services in each site) across sites; and characteristics for V-IMPACT users versus nonusers for 2,155,203 veteran-years in 69 sites across 7 regional networks for FY2013-2018. Regression models assessed the association between V-IMPACT use and veteran characteristics within sites. FINDINGS Across sites, V-IMPACT had higher penetration in rural sites (8%) and primary care community-based outpatient clinics (7%, P<.001). After adjusting for veteran characteristics, rural veterans (aOR = 1.05; P = .02) and veterans with higher comorbidity risk scores (aOR = 1.08; P<.001) were independently associated with V-IMPACT use. Highly rural veterans (OR = 0.60; P<.001) and veterans who lived ≥40 miles from the closest VHA primary care site (OR = 0.86; P<.001) were less likely to be a V-IMPACT user. CONCLUSIONS A clinic-to-clinic telehealth program, such as V-IMPACT, was able to reach many rural sites, rural veterans, and veterans in primary care health professional shortage areas. V-IMPACT has the potential to increase access to team-based primary care.
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Affiliation(s)
- Anna Oh
- San Francisco VA Health Care System, San Francisco, California, USA.,Department of Social and Behavioral Sciences, University of California San Francisco, San Francisco, California, USA
| | - Jennifer Y Scott
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, USA
| | - Adam Chow
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Hao Jiang
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Clara E Dismuke-Greer
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Kritee Gujral
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, California, USA.,Department of General Internal Medicine, University of California San Francisco, San Francisco, California, USA
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Gao J, Moran E, Grimm R, Toporek A, Ruser C. The Effect of Primary Care Visits on Total Patient Care Cost: Evidence From the Veterans Health Administration. J Prim Care Community Health 2022; 13:21501319221141792. [PMID: 36564889 PMCID: PMC9793026 DOI: 10.1177/21501319221141792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Since the 1980s, primary care (PC) in the US has been recognized as the backbone of healthcare providing comprehensive care to complex patients, coordinating care among specialists, and rendering preventive services to contain costs and improve clinical outcomes. However, the effect of PC visits on total patient care cost has been difficult to quantify. OBJECTIVE To assess the effect of PC visits on total patient care cost. METHODS This is a retrospective study of over 5 million patients assigned to a PC provider in the Veterans Health Administration (VHA) in each of the 4 fiscal years (FY 2016-2019). The main outcome of interest is total annual patient care cost. We assessed the effect of primary care visits on total patient care cost first by descriptive statistics, and then by multivariate regressions adjusting for severity of illness and other confounders. We conducted in-depth sensitivity analyses to validate the findings. RESULTS On average, each additional in-person PC visit was associated with a total cost reduction of $721 (per patient per year). The first PC visit was associated with the largest savings, $3976 on average, and a steady diminishing return was observed. Further, the higher the patient risk (severity of illness), the larger the cost reduction: Among the top 10% of high-risk patients, the first PC in-person visit was associated with a reduction of $16 406 (19%). CONCLUSIONS These findings, substantiated by our exhaustive sensitivity analyses, suggest that expanding PC capacity can significantly reduce overall health care costs and improve patient care outcomes given the former is a strong proxy of the latter.
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Affiliation(s)
- Jian Gao
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement,Jian Gao, Department of Veterans Affairs,
Office of Productivity, Efficiency and Staffing, Office of Analytics and
Performance Improvement, 67 Veterans Way, Albany, NY 12208, USA.
| | - Eileen Moran
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | | | - Andrew Toporek
- Department of Veterans Affairs, Office
of Productivity, Efficiency and Staffing (OPES), Office of Analytics and Performance
Improvement
| | - Christopher Ruser
- VACT Healthcare System, Yale University
School of Medicine, New Haven, CT, USA
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Duminy L, Ress V, Wild EM. Complex community health and social care interventions – Which features lead to reductions in hospitalizations for ambulatory care sensitive conditions? A systematic literature review. Health Policy 2022; 126:1206-1225. [DOI: 10.1016/j.healthpol.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/04/2022]
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Gao J, Moran E, Woolhandler S, Toporek A, Wilper AP, Himmelstein DU. Primary Care's Effects on Costs in the US Veterans Health Administration, 2016-2019: an Observational Cohort Study. J Gen Intern Med 2022; 37:3289-3294. [PMID: 34608563 PMCID: PMC9550907 DOI: 10.1007/s11606-021-07140-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/03/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enhancing primary care is a promising strategy for improving the efficiency of health care. Previous studies of primary care's effects on health expenditures have mostly relied on ecological analyses comparing region-wide expenditures rather than spending for individual patients. OBJECTIVE To compare overall medical expenditures for individual patients enrolled vs. those not enrolled in primary care in the Veterans Health Administration (VHA). DESIGN Cohort study with stratification for clinical risk and multivariable linear regression models adjusted for clinical and demographic confounders of expenditures. PARTICIPANTS In total, 6,009,973 VHA patients in fiscal year (FY) 2019-5,410,034 enrolled with a primary care provider (PCP) and 599,939 without a PCP-and similar numbers in FYs 2016-2018. MAIN MEASURES Total annual cost per patient to the VHA (including VHA payments to non-VHA providers) stratified by a composite health risk score previously shown to predict VHA expenditures, and multivariate models additionally adjusted for VHA regional differences, patients' demographic characteristics, non-VHA insurance coverage, and driving time to the nearest VHA facility. Sensitivity analyses explored different modeling strategies and risk adjusters, as well as the inclusion of expenditures by the Medicare program that covers virtually all elderly VHA patients for care not paid for by the VHA. KEY RESULTS Within each health-risk decile, non-PCP patients had higher outpatient, inpatient, and total costs than those with a PCP. After adjustment for health risk and other factors, lack of a PCP was associated 27.4% higher VHA expenditures, $3274 per patient annually (p < .0001). Sensitivity analyses using different risk adjusters and including Medicare's spending for VHA patients yielded similar results. CONCLUSIONS In the VHA system, primary care is associated with substantial cost savings. Investments in primary care in other settings might also be cost-effective.
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Affiliation(s)
- Jian Gao
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Eileen Moran
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Steffie Woolhandler
- City University of New York at Hunter College, New York, NY, USA
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA
| | - Andrew Toporek
- Office of Productivity, Efficiency, and Staffing, Quality and Patient Safety, Office of Analytics and Performance Integration, Department of Veterans Affairs, Albany, NY, USA
| | - Andrew P Wilper
- Boise Veterans Affairs Medical Center, Boise, ID, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - David U Himmelstein
- City University of New York at Hunter College, New York, NY, USA.
- Department of Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA, USA.
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Walters JK, Sharma A, Malica E, Harrison R. Supporting efficiency improvement in public health systems: a rapid evidence synthesis. BMC Health Serv Res 2022; 22:293. [PMID: 35241066 PMCID: PMC8892107 DOI: 10.1186/s12913-022-07694-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 02/23/2022] [Indexed: 12/28/2022] Open
Abstract
Background Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency. Methods Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included. Results Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement. Conclusions The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-07694-z.
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Affiliation(s)
| | | | - Emma Malica
- New South Wales Ministry of Health, St Leonards, Australia
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Wong ES, Rajan S, Liu CF, Morland LA, Pyne JM, Simsek-Duran F, Reisinger HS, Moeckli J, Fortney JC. Economic costs of implementing evidence-based telemedicine outreach for posttraumatic stress disorder in VA. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221116771. [PMID: 37091111 PMCID: PMC9924252 DOI: 10.1177/26334895221116771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Telemedicine outreach for posttraumatic stress disorder (TOP) is a virtual evidence-based practice (EBP) involving telephone care management and telepsychology that engages rural patients in trauma-focused psychotherapy. This evaluation examined implementation and intervention costs attributable to deploying TOP from a health system perspective. Methods Costs were ascertained as part of a stepped wedge cluster randomized trial at five sites within the Veterans Affairs (VA) Healthcare System. All sites initially received a standard implementation strategy, which included internal facilitation, dissemination of an internal facilitators operational guide, funded care manager, care managing training, and technical support. A subset of clinics that failed to meet performance metrics were subsequently randomized to enhanced implementation, which added external facilitation that focused on incorporating TOP clinical processes into existing clinic workflow. We measured site-level implementation activities using project records and structured activity logs tracking personnel-level time devoted to all implementation activities. We monetized time devoted to implementation activities by applying an opportunity cost approach. Intervention costs were measured as accounting-based costs for telepsychiatry/telepsychology and care manager visits, ascertained using VA administrative data. We conducted descriptive analyses of strategy-specific implementation costs across five sites. Descriptive analyses were conducted instead of population-level cost-effectiveness analysis because previous research found enhanced implementation was not more successful than the standard implementation in improving uptake of TOP. Results Over the 40-month study period, four of five sites received enhanced implementation. Mean site-level implementation cost per month was $919 (SD = $238) during standard implementation and increased to $1,651 (SD = $460) during enhanced implementation. Mean site-level intervention cost per patient-month was $46 (SD = $28) during standard implementation and $31 (SD = $21) during enhanced implementation. Conclusions Project findings inform the expected cost of implementing TOP, which represents one factor health systems should consider in the decision to broadly adopt this EBP. Plain Language Summary: What is already known about the topic: Trauma-focused psychotherapy delivered through telemedicine has been demonstrated as an effective approach for the treatment of post-traumatic stress disorder (PTSD). However, uptake of this evidence-based approach by integrated health systems such as the Veterans Affairs (VA) Health Care System is low. What does this paper add: This paper presents new findings on the costs of two implementation approaches designed to increase adoption telemedicine outreach for PTSD from a health system perspective. What are the implications for practice, research, and policy: Cost estimates from this paper can be used by health systems to inform the relative value of candidate implementation strategies to increase adoption of evidence-based treatments for PTSD or other mental health conditions.
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Affiliation(s)
- Edwin S. Wong
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Suparna Rajan
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
| | - Chuan-Fen Liu
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Health Systems and Population Health, University of Washington, Seattle, WA
| | - Leslie A. Morland
- VA San Diego Healthcare System, San Diego, CA
- Department of Psychiatry, University of California-San Diego, San Diego, CA
| | - Jeffrey M. Pyne
- Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR
- Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Fatma Simsek-Duran
- Iowa City VA Health Care System, Iowa City, IA
- Department of Psychiatry, University of Iowa, Iowa City, IA
| | - Heather S. Reisinger
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
- Department of Internal Medicine, University of Iowa, Iowa
City, IA
| | - Jane Moeckli
- Center for Access & Delivery Research and Evaluation, Iowa City VA Health Care System, Iowa City, IA
| | - John C. Fortney
- Center for Innovation for Veteran-Centered and Value-Driven Care, Puget Sound Health Care System, Seattle, WA
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA
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11
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Smith VA, Van Houtven CH, Lindquist JH, Hastings SN. Evaluation of a geriatrics primary care model using prospective matching to guide enrollment. BMC Med Res Methodol 2021; 21:167. [PMID: 34399689 PMCID: PMC8366154 DOI: 10.1186/s12874-021-01360-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 07/01/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Few definitive guidelines exist for rigorous large-scale prospective evaluation of nonrandomized programs and policies that require longitudinal primary data collection. In Veterans Affairs (VA) we identified a need to understand the impact of a geriatrics primary care model (referred to as GeriPACT); however, randomization of patients to GeriPACT vs. a traditional PACT was not feasible because GeriPACT has been rolled out nationally, and the decision to transition from PACT to GeriPACT is made jointly by a patient and provider. We describe our study design used to evaluate the comparative effectiveness of GeriPACT compared to a traditional primary care model (referred to as PACT) on patient experience and quality of care metrics. METHODS We used prospective matching to guide enrollment of GeriPACT-PACT patient dyads across 57 VA Medical Centers. First, we identified matches based an array of administratively derived characteristics using a combination of coarsened exact and distance function matching on 11 identified key variables that may function as confounders. Once a GeriPACT patient was enrolled, matched PACT patients were then contacted for recruitment using pre-assigned priority categories based on the distance function; if eligible and consented, patients were enrolled and followed with telephone surveys for 18 months. RESULTS We successfully enrolled 275 matched dyads in near real-time, with a median time of 7 days between enrolling a GeriPACT patient and a closely matched PACT patient. Standardized mean differences of < 0.2 among nearly all baseline variables indicates excellent baseline covariate balance. Exceptional balance on survey-collected baseline covariates not available at the time of matching suggests our procedure successfully controlled many known, but administratively unobserved, drivers of entrance to GeriPACT. CONCLUSIONS We present an important process to prospectively evaluate the effects of different treatments when randomization is infeasible and provide guidance to researchers who may be interested in implementing a similar approach. Rich matching variables from the pre-treatment period that reflect treatment assignment mechanisms create a high quality comparison group from which to recruit. This design harnesses the power of national administrative data coupled with collection of patient reported outcomes, enabling rigorous evaluation of non-randomized programs or policies.
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Affiliation(s)
- Valerie A Smith
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA.
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA.
- Department of General Internal Medicine, Duke University, 411 W Chapel Hill St Suite 600, NC, Durham, USA.
| | - Courtney Harold Van Houtven
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA
- Duke-Margolis Center for Health Policy, Durham, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, NC, Durham, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
| | - Susan N Hastings
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Health Care System, 411 W Chapel Hill St Suite 600, NC, 27701, Durham, USA
- Department of Population Health Sciences, Duke University School of Medicine, 411 W Chapel Hill St Suite 600, NC, Durham, USA
- Center for the Study of Aging and Human Development, Duke University School of Medicine, NC, Durham, USA
- Department of Medicine, Division of Geriatrics, Duke University School of Medicine, NC, Durham, USA
- Geriatrics Research Education and Clinical Center (GRECC), Durham Veterans Affairs Health Care System, NC, Durham, USA
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Abstract
This quality improvement study assesses the proportion of primary care spending in the Veterans Health Administration in 2014 and 2018.
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Affiliation(s)
- Ashok Reddy
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Karin M. Nelson
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Edwin S. Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle
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13
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Nelson K, Reddy A, Stockdale SE, Rose D, Fihn S, Rosland AM, Stewart G, Denietolis A, Curtis I, Mori A, Rubenstein L. The Primary Care Analytics Team: Integrating research and clinical care within the Veterans Health Administration Office of Primary Care. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 8 Suppl 1:100491. [PMID: 34175100 DOI: 10.1016/j.hjdsi.2020.100491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 09/30/2020] [Accepted: 10/20/2020] [Indexed: 12/01/2022]
Abstract
By designing and evaluating health system improvements and providing evidence to clinical decision-makers, embedded researchers are a critical part of a Learning Health System (LHS). In this article, we describe the evolution and mission of the Primary Care Analytics Team (PCAT), an integrated research team within the Veterans Health Administration Office of Primary Care. We discuss challenges and strategies for success in working with clinical operations partners and provide recommendations for other Learning Health Systems units embedded in large integrated health care organizations.
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Affiliation(s)
- Karin Nelson
- VA Puget Sound Health Care System, Seattle, WA, USA; HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, WA, USA; Division of General Internal Medicine, University of Washington, Seattle, WA, USA.
| | - Ashok Reddy
- VA Puget Sound Health Care System, Seattle, WA, USA; HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound, Seattle, WA, USA; Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Danielle Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Sepulveda, CA, USA
| | - Stephan Fihn
- Division of General Internal Medicine, University of Washington, Seattle, WA, USA
| | - Ann-Marie Rosland
- Center for Health Equity Research and Promotion, VA Pittsburgh, USA; Department of Internal Medicine, University of Pittsburgh, USA
| | - Gregory Stewart
- Department of Management, University of Iowa, Iowa City, IA, USA
| | - Angela Denietolis
- Office of Primary Care, Veterans Health Administration, Washington, DC, USA
| | | | - Alaina Mori
- VA Puget Sound Health Care System, Seattle, WA, USA
| | - Lisa Rubenstein
- The RAND Corporation, Santa Monica, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Hoerster KD, Tanksley L, Sulayman N, Bondzie J, Brier M, Damschroder L, Coggeshall S, Houseknecht D, Hunter-Merrill R, Monty G, Saelens BE, Sayre G, Simpson T, Wong E, Nelson K. Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial. Contemp Clin Trials 2021; 107:106487. [PMID: 34144246 DOI: 10.1016/j.cct.2021.106487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 10/21/2022]
Abstract
Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.
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Affiliation(s)
- Katherine D Hoerster
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; University of Washington, Department of Psychiatry and Behavioral Sciences, 100 NE 45(th) Street, Suite 300, Seattle, WA 98105; United States.
| | - Lamont Tanksley
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States.
| | - Nadiyah Sulayman
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Juliana Bondzie
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Moriah Brier
- VA Puget Sound Healthcare System, Anesthesiology Service, 1660 South Columbian Way, Seattle, WA 98108, United States.
| | - Laura Damschroder
- VA Ann Arbor Center for Clinical Management Research, 2800 Plymouth Rd. NCRC Bldg 16 (152), Ann Arbor, MI 48105, USA.
| | - Scott Coggeshall
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Dakota Houseknecht
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Rachel Hunter-Merrill
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Gillian Monty
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Brian E Saelens
- Seattle Children's Research Institute, 1920 Terry Avenue, Seattle, WA 98101, United States of America; University of Washington, Department of Pediatrics, 1959 NE Pacific Street, Seattle, WA 98195, United States of America.
| | - George Sayre
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Tracy Simpson
- VA Puget Sound Healthcare System, Seattle Division, Mental Health Service; 1660 South Columbian Way (S-116), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States.
| | - Edwin Wong
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States.
| | - Karin Nelson
- VA Puget Sound Healthcare System, Seattle Division, Health Services Research and Development, 1660 South Columbian Way (S-152), Seattle, WA 98108, United States; VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education (CESATE), 1660 South Columbian Way, Seattle, WA 98108, United States; University of Washington, School of Public Health, Department of Health Services, United States; University of Washington, Department of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States.
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15
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Duan KI, Spece LJ, Wong ES, Feemster LC, Donovan LM, Griffith MF, Keller TL, Bryant AD, Au DH. Low-Value Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease and the Association with Healthcare Utilization and Costs. Ann Am Thorac Soc 2021; 18:989-996. [PMID: 33290180 PMCID: PMC8456735 DOI: 10.1513/annalsats.202009-1128oc] [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: 09/11/2020] [Accepted: 12/08/2020] [Indexed: 11/20/2022] Open
Abstract
Rationale: Inhaled corticosteroids (ICS) are not first-line therapy for patients with chronic obstructive pulmonary disease (COPD) at low risk of exacerbations, but they are commonly prescribed despite evidence of harm. We consider ICS prescription in this population to be of "low value." The association of low-value ICS with subsequent healthcare utilization and costs is unknown. Understanding this relationship could inform efforts to reduce the delivery of low-value care. Objectives: To determine whether low-value ICS prescribing is associated with higher outpatient healthcare utilization and costs among patients with COPD who are at low risk of exacerbation. Methods: We performed a cohort study between January 1, 2010, and December 31, 2018, identifying a cohort of veterans with COPD who performed pulmonary function tests (PFTs) at 21 Veterans Affairs medical centers nationwide. Patients were defined as having low exacerbation risk if they experienced less than two outpatient exacerbations and no hospital admissions for COPD in the year before PFTs. Our primary exposure was the receipt of an ICS prescription in the 3 months before the date of PFTs. Our primary outcomes were outpatient utilization and outpatient costs in the 1 year after PFTs. For inference, we generated negative binomial models for utilization and generalized linear models for costs, adjusting for confounders. Results: We identified a total of 31,551 patients with COPD who were at low risk of exacerbation. Of these patients, 9,742 were prescribed low-value ICS (mean [standard deviation (SD)] age, 69 [9] yr), and 21,809 were not prescribed low-value ICS (mean [SD] age, 68 [9] yr). Compared with unexposed patients, those exposed to low-value ICS had 0.53 more encounters per patient per year (95% confidence interval CI, 0.23-0.83) and incurred $154.72 higher costs/patient/year (95% CI, $45.58-$263.86). Conclusions: Low-value ICS prescription was associated with higher subsequent outpatient healthcare utilization and costs. Potential mechanisms for the observed association are that 1) low-value ICS may be a marker of poor respiratory symptom control, 2) there is confounding by indication, or 3) low-value ICS results in increased drug costs or utilization. Health systems should identify low-value ICS prescriptions as a target to improve value-based care.
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Affiliation(s)
- Kevin I. Duan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Laura J. Spece
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Edwin S. Wong
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Department of Health Services, University of Washington, Seattle, Washington
| | - Laura C. Feemster
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Lucas M. Donovan
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Matthew F. Griffith
- Health Services Research and Development, Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado; and
- Division of Pulmonary Sciences and Critical Care, University of Colorado, Aurora, Colorado
| | - Thomas L. Keller
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - Alexander D. Bryant
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
| | - David H. Au
- Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, and
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Abraham TH, Stewart GL, Solimeo SL. The importance of soft skills development in a hard data world: learning from interviews with healthcare leaders. BMC MEDICAL EDUCATION 2021; 21:147. [PMID: 33676503 PMCID: PMC7937235 DOI: 10.1186/s12909-021-02567-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/16/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Learning healthcare systems have invested heavily in training primary care staff to provide care using patient-centered medical home models, but less is known about how to effectively lead such teams to deliver high quality care. Research is needed to better understand which healthcare leadership skills are most utilized or in need of development through additional training. METHOD Semi-structured telephone interviews with healthcare leaders familiar with Patient-Aligned Care Teams (PACT) implementation in the U.S. Department of Veterans Affairs (VA). We interviewed sixteen (N = 16) physician, nursing, and administrative leaders at VA facilities located in the upper Midwestern United States. Content analysis of interviews transcripts using template techniques. RESULTS Participants described instrumental challenges that they perceived hindered leadership effectiveness, including the supervisory structure; pace of change; complexity of the clinical data infrastructure; an over-reliance on technology for communication; and gaps in available leadership training. Factors perceived as facilitating effective leadership included training in soft skills, face-to-face communication, and opportunities for formal training and mentorship. A cross-cutting theme was the importance of developing "soft skills" for effective PACT leadership. CONCLUSIONS Although formal leadership training and development were perceived as beneficial, healthcare leaders familiar with PACT implementation in the VA described a mismatch between the skills and knowledge PACT leaders need to succeed and the training available to them. Closing this gap could improve retention of skilled and knowledgeable healthcare leaders, thereby reducing the costs associated with training and leading to improvements in healthcare delivery.
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Affiliation(s)
- Traci H Abraham
- VA Office of Patient Care Services, Primary Care Analytics Team-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA.
- Center for Mental Healthcare & Outcomes Research (CeMHOR), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Rd., Bldg 58, North Little Rock, AR, 72114, USA.
- Department of Psychiatry, Center for Health Services Research (CHSR), University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Greg L Stewart
- VA Office of Patient Care Services, Primary Care Analytics Team-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA
- Department of Management & Entrepreneurship, Tippie College of Business, University of Iowa, Iowa City, IA, USA
| | - Samantha L Solimeo
- VA Office of Patient Care Services, Primary Care Analytics Team-Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA
- VA Office of Rural Health, Veterans Rural Health Resource Center- Iowa City, Iowa City VA Health Care System, Iowa City, IA, USA
- Center for Access & Delivery Research & Evaluation (CADRE), Iowa City VA Health Care System, Iowa City, IA, USA
- Department of General Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Netw Open 2020; 3:e2020955. [PMID: 33079197 PMCID: PMC7576407 DOI: 10.1001/jamanetworkopen.2020.20955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Ranak B. Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Menlo Park, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Jean Yoon
- VA Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California, San Francisco
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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Wong ES, Guo R, Yoon J, Zulman DM, Asch SM, Ong MK, Chang ET. Impact of VHA's primary care intensive management program on dual system use. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100450. [PMID: 32919588 DOI: 10.1016/j.hjdsi.2020.100450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/11/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Edwin S Wong
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA; Department of Health Services, University of Washington, Magnuson Health Sciences Center, Room H-68, 1959 NE Pacific St., Seattle, WA, 98195, USA.
| | - Rong Guo
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Healthcare System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Department of General Internal Medicine, UCSF School of Medicine, 1545 Divisadero St., San Francisco, CA, 94115, USA
| | - Donna M Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Division of Primary Care and Population Health, Stanford University, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Steven M Asch
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA; Division of Primary Care and Population Health, Stanford University, 1265 Welch Road, Stanford, CA, 94305, USA
| | - Michael K Ong
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
| | - Evelyn T Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Health Care System, 11301 Wilshire Blvd (151), 90073, Los Angeles, CA, USA; Division of General Internal Medicine, David Geffen School of Medicine, University of California Los Angeles, 1100 Glendon Ave #850, Los Angeles, CA, 90024, USA
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19
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Use of the Veterans’ Choice Program and Attrition From Veterans Health Administration Primary Care. Med Care 2020; 58:1091-1097. [DOI: 10.1097/mlr.0000000000001401] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Yoon J, Leung LB, Rubenstein LV, Nelson K, Rose DE, Chow A, Stockdale SE. Greater patient-centered medical home implementation was associated with lower attrition from VHA primary care. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100429. [PMID: 32553525 DOI: 10.1016/j.hjdsi.2020.100429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/23/2020] [Accepted: 04/22/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Patient-centered medical home models such as the Veterans Health Administration (VHA) Patient Aligned Care Team (PACT) model aim to improve primary care through accessible, comprehensive, continuous team-based care. Practices that adhere to patient-centered medical home principles have been found to exhibit higher patient satisfaction, possibly leading to higher retention of patients longitudinally and reducing attrition from care. We examined whether greater PACT implementation was related to lower attrition from VHA primary care. METHODS A national cohort of 1.5 million nonelderly patients with chronic conditions and using VHA primary care in the baseline year (fiscal year 2015) was identified. Attrition was measured as not receiving primary care over two subsequent years. PACT implementation in 863 VHA primary care practices was measured by the PACT Implementation Progress Index (Pi2) across 8 domains. RESULTS Overall, the attrition rate was 4.4%. Predicted attrition was highest for patients treated in practices with the lowest PACT implementation scores (4.8%) compared to 4.0% among patients in practices with the highest PACT implementation scores (difference = -0.8 (95% CI: -1.3, -0.2)). Better performance on most PACT domains was significantly associated with lower attrition. CONCLUSIONS Primary care practices that facilitate easier access to providers as well as provide more seamless care coordination, better communication with providers, and support for self-management appear to positively affect patients' decisions to stay in VHA care. IMPLICATIONS Provision of accessible, comprehensive, team-based primary care, as measured in this study, is likely to be a determinant of patient retention in VHA care. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Jean Yoon
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA; Department of General Internal Medicine, UCSF School of Medicine, San Francisco, CA, USA.
| | - Lucinda B Leung
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Lisa V Rubenstein
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; RAND Corporation, Santa Monica, CA, USA; Department of Health Policy & Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Karin Nelson
- Seattle-Denver Center of Innovation in Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Adam Chow
- VA Health Economics Resource Center, VA Palo Alto Healthcare System, Menlo Park, CA, USA
| | - Susan E Stockdale
- Center for the Study of Healthcare Innovation, Implementation, & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA; Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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21
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Chang ET, Zulman DM, Nelson KM, Rosland AM, Ganz DA, Fihn SD, Piegari R, Rubenstein LV. Use of General Primary Care, Specialized Primary Care, and Other Veterans Affairs Services Among High-Risk Veterans. JAMA Netw Open 2020; 3:e208120. [PMID: 32597993 PMCID: PMC7324956 DOI: 10.1001/jamanetworkopen.2020.8120] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE Integrated health care systems increasingly focus on improving outcomes among patients at high risk for hospitalization. Examining patterns of where patients obtain care could give health care systems insight into how to develop approaches for high-risk patient care; however, such information is rarely described. OBJECTIVE To assess use of general and specialized primary care, medical specialty, and mental health services among patients at high risk of hospitalization in the Veterans Health Administration (VHA). DESIGN, SETTING, AND PARTICIPANTS This national, population-based, retrospective cross-sectional study included all veterans enrolled in any type of VHA primary care service as of September 30, 2015. Data analysis was performed from April 1, 2016, to January 1, 2019. EXPOSURES Risk of hospitalization and assignment to general vs specialized primary care. MAIN OUTCOME AND MEASURES High-risk veterans were defined as those who had the 5% highest risk of near-term hospitalization based on a validated risk prediction model; all others were considered low risk. Health care service use was measured by the number of encounters in general primary care, specialized primary care, medical specialty, mental health, emergency department, and add-on intensive management services (eg, telehealth and palliative care). RESULTS The study assessed 4 309 192 veterans (mean [SD] age, 62.6 [16.0] years; 93% male). Male veterans (93%; odds ratio [OR], 1.11; 95% CI, 1.10-1.13), unmarried veterans (63%; OR, 2.30; 95% CI, 2.32-2.35), those older than 45 years (94%; 45-65 years of age: OR, 3.49 [95% CI, 3.44-3.54]; 66-75 years of age: OR, 3.04 [95% CI, 3.00-3.09]; and >75 years of age: OR, 2.42 [95% CI, 2.38-2.46]), black veterans (23%; OR, 1.63; 95% CI, 1.61-1.64), and those with medical comorbidities (asthma or chronic obstructive pulmonary disease: 33%; OR, 4.03 [95% CI, 4.00-4.06]; schizophrenia: 4%; OR, 5.14 [95% CI, 5.05-5.22]; depression: 42%; OR, 3.10 [95% CI, 3.08-3.13]; and alcohol abuse: 20%; OR, 4.54 [95% CI, 4.50-4.59]) were more likely to be high risk (n = 351 012). Most (308 433 [88%]) high-risk veterans were assigned to general primary care; the remaining 12% (42 579 of 363 561) were assigned to specialized primary care (eg, women's health and homelessness). High-risk patients assigned to general primary care had more frequent primary care visits (mean [SD], 6.9 [6.5] per year) than those assigned to specialized primary care (mean [SD], 6.3 [7.3] per year; P < .001). They also had more medical specialty care visits (mean [SD], 4.4 [5.9] vs 3.7 [5.4] per year; P < .001) and fewer mental health visits (mean [SD], 9.0 [21.6] vs 11.3 [23.9] per year; P < .001). Use of intensive supplementary outpatient services was low overall. CONCLUSIONS AND RELEVANCE The findings suggest that, in integrated health care systems, approaches to support high-risk patient care should be embedded within general primary care and mental health care if they are to improve outcomes for high-risk patient populations.
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Affiliation(s)
- Evelyn T. Chang
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
| | - Donna M. Zulman
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Menlo Park, California
- Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, California
| | - Karin M. Nelson
- Seattle-Denver Health Services Research & Development Center of Innovation, VA Puget Sound Healthcare System, Seattle, Washington
- General Internal Medicine Service, VA Puget Sound Healthcare System, Seattle, Washington
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Ann-Marie Rosland
- VA Pittsburgh Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A. Ganz
- Center for the Study of Healthcare Innovation, Implementation and Policy, Veterans Affairs (VA) Greater Los Angeles Healthcare System, Los Angeles, California
- VA Greater Los Angeles Geriatric Research, Education and Clinical Center, Los Angeles, California
- UCLA Multicampus Program in Geriatric Medicine and Gerontology, Los Angeles, California
| | - Stephan D. Fihn
- Department of Medicine, University of Washington, Seattle
- Department of Health Services, University of Washington, Seattle
| | - Rebecca Piegari
- VA Office of Clinical Systems Development & Evaluation, Washington, DC
| | - Lisa V. Rubenstein
- Division of General Internal Medicine, David Geffen School of Medicine at UCLA (University of California at Los Angeles), Los Angeles
- Fielding School of Public Health, UCLA, Los Angeles, California
- RAND Corporation, Santa Monica, California
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22
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Veet CA, Radomski TR, D'Avella C, Hernandez I, Wessel C, Swart ECS, Shrank WH, Parekh N. Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review. J Gen Intern Med 2020; 35:1276-1284. [PMID: 31907790 PMCID: PMC7174518 DOI: 10.1007/s11606-019-05594-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 11/18/2019] [Accepted: 12/02/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems. METHODS We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes. RESULTS Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently. DISCUSSION Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.
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Affiliation(s)
- Clark A Veet
- Department of Medicine Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Thomas R Radomski
- Department of Medicine Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Inmaculada Hernandez
- Department of Pharmacy and Therapeutics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles Wessel
- Health Sciences Library System, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth C S Swart
- UPMC Center for High-Value Healthcare, UPMC Insurance Services Division, Pittsburgh, PA, USA
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Stockdale SE, Hamilton AB, Bergman AA, Rose DE, Giannitrapani KF, Dresselhaus TR, Yano EM, Rubenstein LV. Assessing fidelity to evidence-based quality improvement as an implementation strategy for patient-centered medical home transformation in the Veterans Health Administration. Implement Sci 2020; 15:18. [PMID: 32183873 PMCID: PMC7079486 DOI: 10.1186/s13012-020-0979-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 03/04/2020] [Indexed: 12/25/2022] Open
Abstract
Background Effective implementation strategies might facilitate patient-centered medical home (PCMH) uptake and spread by targeting barriers to change. Evidence-based quality improvement (EBQI) is a multi-faceted implementation strategy that is based on a clinical-researcher partnership. It promotes organizational change by fostering innovation and the spread of those innovations that are successful. Previous studies demonstrated that EBQI accelerated PCMH adoption within Veterans Health Administration primary care practices, compared with standard PCMH implementation. Research to date has not documented fidelity to the EBQI implementation strategy, limiting usefulness of prior research findings. This paper develops and assesses clinical participants’ fidelity to three core EBQI elements for PCMH (EBQI-PCMH), explores the relationship between fidelity and successful QI project completion and spread (the outcome of EBQI-PCMH), and assesses the role of the clinical-researcher partnership in achieving EBQI-PCMH fidelity. Methods Nine primary care practice sites and seven across-sites, topic-focused workgroups participated (2010–2014). Core EBQI elements included leadership-frontlines priority-setting for QI, ongoing access to technical expertise, coaching, and mentoring in QI methods (through a QI collaborative), and data/evidence use to inform QI. We used explicit criteria to measure and assess EBQI-PCMH fidelity across clinical participants. We mapped fidelity to evaluation data on implementation and spread of successful QI projects/products. To assess the clinical-researcher partnership role in EBQI-PCMH, we analyzed 73 key stakeholder interviews using thematic analysis. Results Seven of 9 sites and 3 of 7 workgroups achieved high or medium fidelity to leadership-frontlines priority-setting. Fidelity was mixed for ongoing technical expertise and data/evidence use. Longer duration in EBQI-PCMH and higher fidelity to priority-setting and ongoing technical expertise appear correlated with successful QI project completion and spread. According to key stakeholders, partnership with researchers, as well as bi-directional communication between leaders and QI teams and project management/data support were critical to achieving EBQI-PCMH fidelity. Conclusions This study advances implementation theory and research by developing measures for and assessing fidelity to core EBQI elements in relationship to completion and spread of QI innovation projects or tools for addressing PCMH challenges. These results help close the gap between EBQI elements, their intended outcome, and the finding that EBQI-PCMH resulted in accelerated adoption of PCMH.
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Affiliation(s)
- Susan E Stockdale
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA. .,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA.
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, USA
| | - Alicia A Bergman
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Danielle E Rose
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA
| | - Karleen F Giannitrapani
- HSR&D Center for Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, CA, USA.,Department of Primary Care and Population Health, Stanford University, Palo Alto, CA, USA
| | | | - Elizabeth M Yano
- HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street (152), Sepulveda, CA, 91343-2039, USA.,Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA
| | - Lisa V Rubenstein
- Department of Health Policy & Management Fielding School of Public Health, University of California, Los Angeles, USA.,Department of Medicine David Geffen School of Medicine, University of California, Los Angeles, USA.,RAND Corporation, Santa Monica, CA, USA
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Liu CF, Hebert PL, Douglas JH, Neely EL, Sulc CA, Reddy A, Sales AE, Wong ES. Outcomes of primary care delivery by nurse practitioners: Utilization, cost, and quality of care. Health Serv Res 2020; 55:178-189. [PMID: 31943190 DOI: 10.1111/1475-6773.13246] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To examine whether nurse practitioner (NP)-assigned patients exhibited differences in utilization, costs, and clinical outcomes compared to medical doctor (MD)-assigned patients. DATA SOURCES Veterans Affairs (VA) administrative data capturing characteristics, outcomes, and provider assignments of 806 434 VA patients assigned to an MD primary care provider (PCP) who left VA practice between 2010 and 2012. STUDY DESIGN We applied a difference-in-difference approach comparing outcomes between patients reassigned to MD and NP PCPs, respectively. We examined measures of outpatient (primary care, specialty care, and mental health) and inpatient (total and ambulatory care sensitive hospitalizations) utilization, costs (outpatient, inpatient and total), and clinical outcomes (control of hemoglobin A1c, LDL, and blood pressure) in the year following reassignment. PRINCIPAL FINDINGS Compared to MD-assigned patients, NP-assigned patients were less likely to use primary care and specialty care services and incurred fewer total and ambulatory care sensitive hospitalizations. Differences in costs, clinical outcomes, and receipt of diagnostic tests between groups were not statistically significant. CONCLUSIONS Patients reassigned to NPs experienced similar outcomes and incurred less utilization at comparable cost relative to MD patients. NPs may offer a cost-effective approach to addressing anticipated shortages of primary care physicians.
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Affiliation(s)
- Chuan-Fen Liu
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington
| | - Paul L Hebert
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Jamie H Douglas
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Emily L Neely
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Christine A Sulc
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
| | - Ashok Reddy
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington.,Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington
| | - Anne E Sales
- Center of Innovation for Clinical Management Research, Ann Arbor, Michigan.,Division of Learning and Knowledge Systems, University of Michigan Medical School, Ann Arbor, Michigan
| | - Edwin S Wong
- Department of Health Services, Magnuson Health Sciences Center, University of Washington School of Public Health, Seattle, Washington.,Center of Innovation for Veteran-Centered and Value-Driven Care, VA Puget Sound Health Care System, Seattle, Washington
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25
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Predicting Primary Care Use Among Patients in a Large Integrated Health System: The Role of Patient Experience Measures. Med Care 2019; 57:608-614. [PMID: 31295190 DOI: 10.1097/mlr.0000000000001155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Most Veterans Affairs (VA) Health Care System enrollees age 65+ also have the option of obtaining care through Medicare. Reliance upon VA varies widely and there is a need to optimize its prediction in an era of expanding choice for veterans to obtain care within or outside of VA. We examined whether survey-based patient-reported experiences improved prediction of VA reliance. METHODS VA and Medicare claims in 2013 were linked to construct VA reliance (proportion of all face-to-face primary care visits), which was dichotomized (=1 if reliance >50%). We predicted reliance in 83,143 Medicare-eligible veterans as a function of 61 baseline characteristics in 2012 from claims and the 2012 Survey of Healthcare Experiences of Patients. We estimated predictive performance using the cross-validated area under the receiver operating characteristic (AUROC) curve, and assessed variable importance using the Shapley value decomposition. RESULTS In 2012, 68.9% were mostly VA reliant. The AUROC for the model including claims-based predictors was 0.882. Adding patient experience variables increased AUROC to 0.890. The pseudo R for the full model was 0.400. Baseline reliance and patient experiences accounted for 72.0% and 11.1% of the explained variation in reliance. Patient experiences related to the accessibility of outpatient services were among the most influential predictors of reliance. CONCLUSION The addition of patient experience variables slightly increased predictive performance. Understanding the relative importance of patient experience factors is critical for informing what VA reform efforts should be prioritized following the passage of the 2018 MISSION Act.
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26
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Leung LB, Rubenstein LV, Yoon J, Post EP, Jaske E, Wells KB, Trivedi RB. Veterans Health Administration Investments In Primary Care And Mental Health Integration Improved Care Access. Health Aff (Millwood) 2019; 38:1281-1288. [DOI: 10.1377/hlthaff.2019.00270] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lucinda B. Leung
- Lucinda B. Leung is a core investigator in the Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, and an assistant professor of medicine in the Division of General Internal Medicine and Health Services Research at the University of California Los Angeles (UCLA) David Geffen School of Medicine
| | - Lisa V. Rubenstein
- Lisa V. Rubenstein is a professor emerita of medicine in the Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, and the Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Jean Yoon
- Jean Yoon is a health economist at the Health Economics Resource Center, VA Palo Alto Healthcare System, in Menlo Park, California, and the University of California San Francisco
| | - Edward P. Post
- Edward P. Post is the national Primary Care–Mental Health Integration medical director in the Veterans Health Administration based out of the VA Ann Arbor Healthcare System and a professor of medicine in the Division of General Medicine, University of Michigan, in Ann Arbor
| | - Erin Jaske
- Erin Jaske is a data analyst in the Primary Care Analytics Team, VA Puget Sound Healthcare System, in Seattle, Washington
| | - Kenneth B. Wells
- Kenneth B. Wells is the director of the UCLA Center for Health Services and Society; a professor of psychiatry in the Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior; and an associate investigator at the VA HSR&D Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System
| | - Ranak B. Trivedi
- Ranak B. Trivedi is a core investigator at the Center for Innovation to Implementation, VA Palo Alto Healthcare System, and an assistant professor of psychiatry in the Department of Public Mental Health and Population Sciences, Stanford University, in Menlo Park, California
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Offsetting Patient-Centered Medical Homes Investment Costs Through Per-Member-Per-Month or Medicare Merit-based Incentive Payment System Incentive Payments. J Ambul Care Manage 2019; 41:105-113. [PMID: 29298177 DOI: 10.1097/jac.0000000000000224] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Primary care practices become patient-centered medical homes (PCMHs) to improve care. However, investment costs and opportunities to offset those costs are critical to the decision. We examined potential offsets through commercial payer per-member-per-month (PMPM) payments and the Medicare Merit-based Incentive Payment System (MIPS) for a network that spent $4 818 260 over 4 years obtaining and renewing PCMH recognition for 57 practices. With PMPM payments of $3.37 to $8.98, "breakeven" requires that 2.4% to 6.4% of the network's 1645 commercially insured patients per physician be covered, while applying MIPS incentive payments of half the maximum available each year to the network's average 2016 Medicare reimbursement of $196 812 per physician showed they would exceed PCMH costs by 2022.
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28
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Waters TM, Kaplan CM, Graetz I, Price MM, Stevens LA, McAneny BL. Patient-Centered Medical Homes in Community Oncology Practices: Changes in Spending and Care Quality Associated With the COME HOME Experience. J Oncol Pract 2019; 15:e56-e64. [DOI: 10.1200/jop.18.00479] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE: We examined whether the Community Oncology Medical Home (COME HOME) program, a medical home program implemented in seven community oncology practices, was associated with changes in spending and care quality. PATIENTS AND METHODS: We compared outcomes from elderly fee-for-service Medicare beneficiaries diagnosed between 2011 and 2015 with breast, lung, colorectal, thyroid, or pancreatic cancer, lymphoma, or melanoma and served by COME HOME practices before and after program implementation versus similar beneficiaries served by other geographically proximate oncologists. Difference-in-differences analysis compared changes in outcomes for COME HOME patients versus concurrent controls. Propensity score matching and regression methods were adjusted for clinical and sociodemographic differences. Our primary outcome was 6-month medical spending per beneficiary. Secondary outcomes included 6-month out-of-pocket spending, inpatient and ambulatory care–sensitive hospitalizations, readmissions, length of stay, and emergency department and evaluation and management visits. RESULTS: Before COME HOME, 6-month medical spending was $2,975 higher for the study group compared with controls (95% CI, $1,635 to $4,315; P < .001) and increasing at a similar rate. After intervention, this difference was reduced to $318 (95% CI, −$1,105 to $1,741; P = .661), a significant change of −$2,657 (95% CI, −$4,631 to −$683; P = .008) or 8.1% savings relative to 6-month average spending ($32,866). COME HOME was also associated with significantly reduced (10.2 %) emergency department visits per 1,000 patients per 6-month period ( P = .024). There were no statistically significant differences in other outcomes. CONCLUSION: COME HOME was associated with reduced Medicare spending and improved emergency department use. The patient-centered medical home model holds promise for oncology practices, but improvements were not uniform.
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Affiliation(s)
- Teresa M. Waters
- University of Kentucky College of Public Health, Lexington, KY
- University of Tennessee Health Science Center, Memphis, TN
| | | | - Ilana Graetz
- University of Tennessee Health Science Center, Memphis, TN
| | - Mary M. Price
- Mongan Institute, Massachusetts General Hospital, Boston, MA
| | - Laura A. Stevens
- Innovative Oncology Business Solutions, Albuquerque, NM
- National Cancer Care Alliance, Dover, DE
| | - Barbara L. McAneny
- Innovative Oncology Business Solutions, Albuquerque, NM
- New Mexico Oncology Hematology Consultants, Albuquerque, NM
- American Medical Association Board of Trustees, Chicago, IL
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Liu C, Batten A, Wong ES, Fihn SD, Hebert PL. Fee-for-Service Medicare-Enrolled Elderly Veterans Are Increasingly Voting with Their Feet to Use More VA and Less Medicare, 2003-2014. Health Serv Res 2018; 53 Suppl 3:5140-5158. [PMID: 30151827 PMCID: PMC6235817 DOI: 10.1111/1475-6773.13029] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
OBJECTIVE To examine the long-term reliance on outpatient care at the population (i.e., system) level among fee-for-service Medicare-enrolled elderly veterans in the Department of Veterans Affairs (VA) health care system and Medicare from 2003 to 2014. DATA SOURCES/STUDY SETTING We analyzed a 5 percent random sample, stratified by facility, age, gender, and race, of Medicare-enrolled veterans enrolled in a VA primary care panel using VA administrative data and Medicare claims. STUDY DESIGN We performed a repeated cross-sectional analysis over 48 quarters. VA reliance was defined at the system level as the proportion of total visits (VA + Medicare) that occurred in VA. We examined four visit types and seven high-volume medical subspecialties. We applied direct standardization adjusting for age, gender, and race using the 2010 population distribution of Medicare-enrolled veterans. PRINCIPAL FINDINGS Over the 12-year period, VA provided the vast majority of mental health care. Conversely, veterans received slightly more than half of their primary care and most of their specialty care, surgical care, and seven high-volume medical subspecialties through Medicare. However, reliance on VA outpatient care steadily increased over time for all categories of care. CONCLUSIONS Despite the controversies about VA access to care, Medicare-enrolled veterans, who have a choice of using VA or Medicare providers, appear to increase their use of VA care prior to the Choice Act.
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Affiliation(s)
- Chuan‐Fen Liu
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
| | - Adam Batten
- Office of Clinical System Development and EvaluationVeterans Health AdministrationSeattleWA
| | - Edwin S. Wong
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
| | - Stephan D. Fihn
- Department of Health ServicesUniversity of WashingtonSeattleWA
- Department of MedicineUniversity of WashingtonSeattleWA
| | - Paul L. Hebert
- Center of Innovation for Veteran‐Centered and Value‐Driven CareVA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of WashingtonSeattleWA
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Reddy A, Wong E, Canamucio A, Nelson K, Fihn SD, Yoon J, Werner RM. Association between Continuity and Team-Based Care and Health Care Utilization: An Observational Study of Medicare-Eligible Veterans in VA Patient Aligned Care Team. Health Serv Res 2018; 53 Suppl 3:5201-5218. [PMID: 30206936 DOI: 10.1111/1475-6773.13042] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE It remains unknown whether high-functioning teams can compensate for poor continuity of care to support important patient outcomes. DATA SOURCE Linked VA administrative and Medicare claims data to measure the relationship of team-based care and continuity of care with high-cost utilization. STUDY DESIGN Retrospective cohort study of 1.2 million VA-Medicare dual eligible Veterans assigned to a VA primary care provider (PCP) in 2012. Continuity was the proportion of primary care visits to the assigned VA provider of care. Clinics were categorized as low, average, or high-team functioning based on survey data. Our primary outcomes were the number of all-cause hospitalizations, ambulatory care sensitive (ACSC) hospitalizations, and emergency department (ED) visits in 2013. PRINCIPAL FINDINGS A 10-percentage point increase in continuity with a VA PCP was associated with 4.5 fewer hospitalizations (p < .001), 3.2 fewer ACSC hospitalizations (p < .001), and 2.6 more ED visits (p = .07) per 1,000 patients. Team-based care was not significantly associated with any high-cost utilization category. Associations were heterogeneous across VA-reliant and nonreliant Veterans. Finally, the interaction results demonstrated that the quality of team-based care functioning could not compensate for poor continuity on hospitalizations, ACSC hospitalizations, or ED visits. CONCLUSIONS In Veterans who were reliant on the VA for services, increasing continuity with a VA PCP and high-functioning team-based care clinics was associated with fewer ED visits and hospitalizations. Furthermore, leveraging combined data from VA and Medicare allowed to better measure continuity and assess high-cost utilization among Veterans who are and are not reliant on the VA for services.
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Affiliation(s)
- Ashok Reddy
- VA Puget Sound HSR&D, Seattle.,Department of Medicine, School of Medicine, University of Washington, Seattle, WA
| | - Edwin Wong
- VA Puget Sound Healthcare System Health Services Research & Development, Seattle, WA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Anne Canamucio
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA
| | - Karin Nelson
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA.,VA Puget Sound Healthcare System Health Services Research & Development, Seattle, WA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Stephan D Fihn
- Department of Medicine, School of Medicine, University of Washington, Seattle, WA.,Department of Health Services, University of Washington School of Public Health, Seattle, WA
| | - Jean Yoon
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA
| | - Rachel M Werner
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, PA.,Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA
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Rosland A, Wong E, Maciejewski M, Zulman D, Piegari R, Fihn S, Nelson K. Patient-Centered Medical Home Implementation and Improved Chronic Disease Quality: A Longitudinal Observational Study. Health Serv Res 2018; 53:2503-2522. [PMID: 29154464 PMCID: PMC6052009 DOI: 10.1111/1475-6773.12805] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine associations between clinics' extent of patient-centered medical home (PCMH) implementation and improvements in chronic illness care quality. DATA SOURCE Data from 808 Veterans Health Administration (VHA) primary care clinics nationwide implementing the Patient Aligned Care Teams (PACT) PCMH initiative, begun in 2010. DESIGN Clinic-level longitudinal observational study of clinics that received training and resources to implement PACT. Clinics varied in the extent they had PACT components in place by 2012. DATA COLLECTION Clinical care quality measures reflecting intermediate outcomes and care processes related to coronary artery disease (CAD), diabetes, and hypertension care were collected by manual chart review at each VHA facility from 2009 to 2013. FINDINGS In adjusted models containing 808 clinics, the 77 clinics with the most PACT components in place had significantly larger improvements in five of seven chronic disease intermediate outcome measures (e.g., BP < 160/100 in diabetes), ranging from 1.3 percent to 5.2 percent of the patient population meeting measures, and two of eight process measures (HbA1c measurement, LDL measurement in CAD) than the 69 clinics with the least PACT components. Clinics with moderate levels of PACT components showed few significantly larger improvements than the lowest PACT clinics. CONCLUSIONS Veterans Health Administration primary care clinics with the most PCMH components in place in 2012 had greater improvements in several chronic disease quality measures in 2009-2013 than the lowest PCMH clinics.
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Affiliation(s)
- Ann‐Marie Rosland
- VA Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghPA
- Department of Internal MedicineUniversity of Pittsburgh School of MedicinePittsburghPA
- University Drive(151C) 4100 Allequippa StPittsburghPA15213
| | - Edwin Wong
- VA Puget Sound Health Care SystemSeattleWA
- Department of Health ServicesUniversity of Washington School of Public HealthSeattleWA
| | - Matthew Maciejewski
- VA Center for Health Services Research in Primary CareVA DurhamDurhamNC
- Department of Internal MedicineDuke University School of MedicineDurhamNC
| | - Donna Zulman
- VA Center for Innovation to ImplementationVA Palo Alto Health Care SystemMenlo ParkCA
- Department of MedicineStanford UniversityStanfordCA
| | - Rebecca Piegari
- VHA Office of Clinical Systems Development and EvaluationVeterans Health AdministrationWashingtonDC
| | - Stephan Fihn
- VHA Office of Clinical Systems Development and EvaluationVeterans Health AdministrationWashingtonDC
- Department of MedicineUniversity of Washington Medical SchoolSeattleWA
| | - Karin Nelson
- VA Puget Sound Health Care SystemSeattleWA
- Department of MedicineUniversity of Washington Medical SchoolSeattleWA
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Yoon J, Chang E, Rubenstein LV, Park A, Zulman DM, Stockdale S, Ong MK, Atkins D, Schectman G, Asch SM. Impact of Primary Care Intensive Management on High-Risk Veterans' Costs and Utilization: A Randomized Quality Improvement Trial. Ann Intern Med 2018; 168:846-854. [PMID: 29868706 DOI: 10.7326/m17-3039] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary care models that offer comprehensive, accessible care to all patients may provide insufficient resources to meet the needs of patients with complex conditions who have the greatest risk for hospitalization. OBJECTIVE To assess whether augmenting usual primary care with team-based intensive management lowers utilization and costs for high-risk patients. DESIGN Randomized quality improvement trial. (ClinicalTrials.gov: NCT03100526). SETTING 5 U.S. Department of Veterans Affairs (VA) medical centers. PATIENTS Primary care patients at high risk for hospitalization who had a recent acute care episode. INTERVENTION Locally tailored intensive management programs providing care coordination, goals assessment, health coaching, medication reconciliation, and home visits through an interdisciplinary team, including a physician or nurse practitioner, a nurse, and psychosocial experts. MEASUREMENTS Utilization and costs (including intensive management program expenses) 12 months before and after randomization. RESULTS 2210 patients were randomly assigned, 1105 to intensive management and 1105 to usual care. Patients had a mean age of 63 years and an average of 7 chronic conditions; 90% were men. Of the patients assigned to intensive management, 487 (44%) received intensive outpatient care (that is, ≥3 encounters in person or by telephone) and 204 (18%) received limited intervention. From the pre- to postrandomization periods, mean inpatient costs decreased more for the intensive management than the usual care group (-$2164 [95% CI, -$7916 to $3587]). Outpatient costs increased more for the intensive management than the usual care group ($2636 [CI, $524 to $4748]), driven by greater use of primary care, home care, telephone care, and telehealth. Mean total costs were similar in the 2 groups before and after randomization. LIMITATIONS Sites took up to several months to contact eligible patients, limiting the time between treatment and outcome assessment. Only VA costs were assessed. CONCLUSION High-risk patients with access to an intensive management program received more outpatient care with no increase in total costs. PRIMARY FUNDING SOURCE Veterans Health Administration Primary Care Services.
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Affiliation(s)
- Jean Yoon
- U.S. Department of Veterans Affairs Health Economics Resource Center and Center for Innovation to Implementation, Menlo Park, California, and University of California, San Francisco, School of Medicine, San Francisco, California (J.Y.)
| | - Evelyn Chang
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, California (E.C., M.K.O.)
| | - Lisa V Rubenstein
- University of California, Los Angeles, Los Angeles, California, and RAND Corporation, Santa Monica, California (L.V.R.)
| | - Angel Park
- U.S. Department of Veterans Affairs Health Economics Resource Center, Menlo Park, California (A.P.)
| | - Donna M Zulman
- U.S. Department of Veterans Affairs Center for Innovation to Implementation, Menlo Park, California, and Stanford University School of Medicine, Stanford, California (D.M.Z., S.M.A.)
| | - Susan Stockdale
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy and University of California, Los Angeles, Los Angeles, California (S.S.)
| | - Michael K Ong
- U.S. Department of Veterans Affairs Center for the Study of Healthcare Innovation, Implementation and Policy, University of California, Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, California (E.C., M.K.O.)
| | - David Atkins
- U.S. Department of Veterans Affairs Health Services Research and Development, Washington, DC (D.A.)
| | - Gordon Schectman
- U.S. Department of Veterans Affairs Primary Care, Washington, DC (G.S.)
| | - Steven M Asch
- U.S. Department of Veterans Affairs Center for Innovation to Implementation, Menlo Park, California, and Stanford University School of Medicine, Stanford, California (D.M.Z., S.M.A.)
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Tuepker A, Newell S, Nicolaidis C, Reyes ME, González-Prats MC, Skaperdas E, Kansagara D. Veteran Patient Perspectives and Experiences During Implementation of a Patient-Centered Medical Home Model. J Patient Exp 2018; 5:107-113. [PMID: 29978026 PMCID: PMC6022940 DOI: 10.1177/2374373517731602] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The Veterans Health Administration (VA) has implemented the largest shift to a patient-centered medical home (PCMH) model of care in the United States to date. OBJECTIVE We interviewed veterans about their experiences of primary care to understand whether they observed changes in care during this period as well as to learn which characteristics of care mattered most to their experiences. METHOD Qualitative interviews were conducted with 32 veterans receiving primary care at 1 of 8 VA clinics in the northwest United States. Interviews were analyzed using an inductive-deductive hybrid approach by an interdisciplinary team that included a veteran patient. RESULT Participants noticed recent positive changes, including improved communications and shorter waits in clinic, but rarely were aware of VA's PCMH initiative; a strong relationship with the primary care provider and feeling cared for/respected by everyone involved in care delivery were key components of quality care. The needs of the veteran community as a whole also shaped discussion of care expectations. CONCLUSION The PCMH model may provide benefits even when invisible to patients. Veteran awareness of population needs suggests a promising role for veteran involvement in further PCMH transformation efforts.
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Affiliation(s)
- Anaïs Tuepker
- VA Portland Health Care System, Portland, OR, USA
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Summer Newell
- VA Portland Health Care System, Portland, OR, USA
- Department of Sociology, Portland State University, Portland, OR, USA
| | - Christina Nicolaidis
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
- School of Social Work, Portland State University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University and Portland State University, Portland, OR, USA
| | | | | | - Eleni Skaperdas
- Department of Sociology, University of California, Los Angeles, CA, USA
| | - Devan Kansagara
- VA Portland Health Care System, Portland, OR, USA
- Division of General Internal Medicine and Geriatrics, Oregon Health & Science University, Portland, OR, USA
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Chang ET, Zulman DM, Asch SM, Stockdale SE, Yoon J, Ong MK, Lee M, Simon A, Atkins D, Schectman G, Kirsh SR, Rubenstein LV. An operations-partnered evaluation of care redesign for high-risk patients in the Veterans Health Administration (VHA): Study protocol for the PACT Intensive Management (PIM) randomized quality improvement evaluation. Contemp Clin Trials 2018; 69:65-75. [PMID: 29698772 DOI: 10.1016/j.cct.2018.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Patient-centered medical homes have made great strides providing comprehensive care for patients with chronic conditions, but may not provide sufficient support for patients at highest risk for acute care use. To address this, the Veterans Health Administration (VHA) initiated a five-site demonstration project to evaluate the effectiveness of augmenting the VA's Patient Aligned Care Team (PACT) medical home with PACT Intensive Management (PIM) teams for Veterans at highest risk for hospitalization. METHODS/DESIGN Researchers partnered with VHA leadership to design a mixed-methods prospective multi-site evaluation that met leadership's desire for a rigorous evaluation conducted as quality improvement rather than research. We conducted a randomized QI evaluation and assigned high-risk patients to participate in PIM and compared them with high-risk Veterans receiving usual care through PACT. The summative evaluation examines whether PIM: 1) decreases VHA emergency department and hospital use; 2) increases satisfaction with VHA care; 3) decreases provider burnout; and 4) generates positive returns on investment. The formative evaluation aims to support improved care for high-risk patients at demonstration sites and to inform future initiatives for high-risk patients. The evaluation was reviewed by representatives from the VHA Office of Research and Development and the Office of Research Oversight and met criteria for quality improvement. DISCUSSION VHA aims to function as a learning organization by rapidly implementing and rigorously testing QI innovations prior to final program or policy development. We observed challenges and opportunities in designing an evaluation consistent with QI standards and operations priorities, while also maintaining scientific rigor. TRIAL REGISTRATION This trial was retrospectively registered at ClinicalTrials.gov on April 3, 2017: NCT03100526. Protocol v1, FY14-17.
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Affiliation(s)
- Evelyn T Chang
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Donna M Zulman
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States.
| | - Steven M Asch
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; Division of General Medical Disciplines, Stanford University School of Medicine, Stanford, CA, United States.
| | - Susan E Stockdale
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, CA, United States.
| | - Jean Yoon
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, United States; VA Health Economics Resource Center, Menlo Park, CA, United States.
| | - Michael K Ong
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Martin Lee
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States.
| | - Alissa Simon
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States.
| | - David Atkins
- VA Office of Health Services Research and Development, Washington, DC, United States.
| | | | - Susan R Kirsh
- VA Office of Primary Care, Washington, DC, United States; Case Western Reserve University School of Medicine, Cleveland, OH, United States.
| | - Lisa V Rubenstein
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Medicine, Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, United States; Fielding School of Public Health, University of California at Los Angeles, Los Angeles, CA, United States; RAND, Santa Monica, CA, United States.
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Khan S, Spotts HE, Lindblad PC, Spooner JJ. Patient centred medical home (PCMH) and patient-practitioner orientation: Is there a relationship? Int J Clin Pract 2018; 72:e13092. [PMID: 29732687 DOI: 10.1111/ijcp.13092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/25/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The patient-centred medical home (PCMH) and utilisation of a patient-centred care approach have been promoted as opportunities to improve healthcare quality while controlling expenditures. OBJECTIVES To determine the penetration of PCMH within physician practices, and to evaluate physician attitudes towards patient-practitioner orientation. The ultimate objective was to explore relationships between the patient-practitioner orientation of respondents and the presence of PCMH elements within their practice. METHODS A survey instrument was developed following a comprehensive literature review. Lead physicians practicing in four states were surveyed. RESULTS The adjusted response rate was 26.7%. Responses indicated increased utilisation of PCMH elements (electronic medical records, e-mail and telephone consultations, and physician performance monitoring and feedback) compared with previous research. Within a logistic regression model, medical school graduation year (1990 or later >prior to 1990), practice size (group >solo), and percentage of time allocated to patient care (less >more) were significant predictors of working in a high PCMH alignment setting. Physician and practice characteristics did not predict the level of patient-practitioner orientation, though rural physicians were more patient-centred than urban physicians. A non-linear correlation between patient-practitioner orientation and the likelihood of practicing in a low or high PCMH-aligned practice was observed. CONCLUSIONS There is a non-linear correlation between patient-practitioner orientation and the likelihood of a physician practicing in a low or high PCMH-aligned practice. The ability of a physician to work in a PCMH setting or practicing patient-centred care can go beyond a physician's aspirations to work and practice in that manner.
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Affiliation(s)
- Shamima Khan
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA
- CRE Services, Inc., New York, NY, USA
| | - Harlan E Spotts
- College of Business, Western New England University, Springfield, MA, USA
| | - Peter C Lindblad
- The University of Massachusetts Medical School, Worcester, MA, USA
| | - Joshua J Spooner
- College of Pharmacy and Health Sciences, Western New England University, Springfield, MA, USA
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Crowley ST, Murphy K. Delivering a "New Deal" of Kidney Health Opportunities to Improve Outcomes Within the Veterans Health Administration. Am J Kidney Dis 2018; 72:444-450. [PMID: 29627134 DOI: 10.1053/j.ajkd.2018.01.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/22/2018] [Indexed: 11/11/2022]
Abstract
Just as the "New Deal" aimed to elevate the "forgotten man" of the Great Depression through governmental relief and reform, so does the Department of Veterans Affairs (VA) health care system aim to improve the health of veterans with the invisible illness of chronic kidney disease through a concerted series of health care delivery reforms. Augmenting its primary care platform with advances in informatics and health service delivery initiatives targeting kidney disease, the VA is changing how nephrology care is provided to veterans with the goal of optimized population kidney health. As the largest provider of kidney health services in the country, the VA offers an instructive case study of the value of comprehensive health care coverage for people with chronic kidney disease. Recent reports of kidney health outcomes among veterans support the benefit of the VA's integrated health care delivery system. Suggestions to optimize veterans' kidney health further may be equally applicable to other health systems caring for people afflicted with kidney disease.
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Affiliation(s)
- Susan T Crowley
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT; Section of Nephrology, Department of Medicine, Yale University School of Medicine, West Haven, CT.
| | - Katherine Murphy
- Veterans Health Administration, Specialty Care Services/Office of Policy and Services, West Haven, CT
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Fostering evidence-based quality improvement for patient-centered medical homes: Initiating local quality councils to transform primary care. Health Care Manage Rev 2018; 43:168-180. [DOI: 10.1097/hmr.0000000000000138] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chang ET, Raja PV, Stockdale SE, Katz ML, Zulman DM, Eng JA, Hedrick KH, Jackson JL, Pathak N, Watts B, Patton C, Schectman G, Asch SM. What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:231-237. [PMID: 29102480 DOI: 10.1016/j.hjdsi.2017.10.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/22/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
Abstract
Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.
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Affiliation(s)
- Evelyn T Chang
- Department of General Internal Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States; Department of Medicine, University of California at Los Angeles, Los Angeles, CA, United States; VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States.
| | - Pushpa V Raja
- Department of Psychiatry, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States.
| | - Susan E Stockdale
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States; Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, CA, United States.
| | - Marian L Katz
- VA Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, CA, United States.
| | - Donna M Zulman
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, United States.
| | - Jessica A Eng
- Geriatrics, Palliative, and Extended Care Service line, San Francisco VA Medical Center, San Francisco, CA, United States; Division of Geriatrics, University of California San Francisco, San Francisco, CA, United States.
| | - Kathy H Hedrick
- W.G. (Bill) Hefner VA Medical Center, Salisbury, NC, United States.
| | - Jeffrey L Jackson
- Department of Medicine, Zablocki VA Medical Center, Milwaukee, WI, United States; Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States.
| | - Neha Pathak
- Department of Medicine, Atlanta VA Medical Center, Atlanta, GA, United States; Department of Medicine, Emory University, Atlanta, GA, United States.
| | - Brook Watts
- Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States; Departments of Medicine and Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, United States.
| | - Carrie Patton
- VA Office of Primary Care Services, Washington, DC, United States.
| | - Gordon Schectman
- VA Office of Primary Care Services, Washington, DC, United States.
| | - Steven M Asch
- VA Center for Innovation to Implementation (Ci2i), Menlo Park, CA, USA; Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA, United States.
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Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care. Med Care 2017; 55 Suppl 9 Suppl 2:S104-S110. [DOI: 10.1097/mlr.0000000000000770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Durfee J, Johnson T, Batal H, Long J, Rinehart D, Everhart R, Oronce CI, Douglas I, Moore K, Atherly A. The impact of tailored intervention services on charges and mortality for adult super-utilizers. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2017; 6:253-258. [PMID: 28847571 DOI: 10.1016/j.hjdsi.2017.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/11/2017] [Accepted: 08/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Interventions designed to improve care and reduce costs for patients with the highest rates of hospital utilization (super-utilizers) continue to proliferate, despite conflicting evidence of cost savings. METHODS We evaluated a practice transformation intervention that implemented team-based care and risk-stratification to match specific primary care resources based on need. This included an intensive outpatient clinic for super-utilizers. We used multivariate regression and a difference-in-differences approach to compare changes in mortality, utilization, and charges between the intervention group and a historical control. Sensitivity analyses tested the robustness of findings and revealed the inherent challenges associated with quasi-experimental designs. RESULTS Observed charges for the intervention group were significantly lower than expected charges as derived by the trend of the historical control (p<0.04) resulting in total charge avoidance of approximately $26 million. While inpatient admissions were significantly higher (p<0.01), charges associated with total inpatient (p=0.01), intensive-care unit (p<0.05, not robust to sensitivity analyses), and surgery (p<0.01) were significantly lower than expected in the intervention group. One year mortality was significantly less in the intervention group (12.6% vs 11.5%, p<0.01). CONCLUSIONS The use of tailored services, including a dedicated intensive outpatient clinic, for super-utilizers within a larger primary care practice transformation reduced mortality and provided significant savings, even while total hospitalizations increased. These savings were achieved through a reduction in the intensity of inpatient services. The unexpected finding of a reduction in ICU charges deserves further exploration. IMPLICATIONS These findings suggest that intensity of inpatient service, and not merely volume of services, should be considered a focus for future intervention design and evaluated as an outcome. LEVEL OF EVIDENCE Level III (Quasi-Experimental Design).
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Affiliation(s)
- Josh Durfee
- Denver Health and Hospital Association, Denver, CO, USA
| | - Tracy Johnson
- Denver Health and Hospital Association, Denver, CO, USA
| | - Holly Batal
- Denver Health and Hospital Association, Denver, CO, USA
| | - Jeremy Long
- Denver Health and Hospital Association, Denver, CO, USA
| | | | | | | | - Ivor Douglas
- Denver Health and Hospital Association, Denver, CO, USA; University of Colorado, School of Medicine, Aurora, CO, USA
| | | | - Adam Atherly
- University of Colorado, School of Public Health, Aurora, CO, USA
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Morgan P, Everett CM, Smith VA, Woolson S, Edelman D, Hendrix CC, Berkowitz TSZ, White B, Jackson GL. Factors Associated With Having a Physician, Nurse Practitioner, or Physician Assistant as Primary Care Provider for Veterans With Diabetes Mellitus. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2017; 54:46958017712762. [PMID: 28617196 PMCID: PMC5558456 DOI: 10.1177/0046958017712762] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Expanded use of nurse practitioners (NPs) and physician assistants (PAs) is a potential solution to workforce issues, but little is known about how NPs and PAs can best be used. Our study examines whether medical and social complexity of patients is associated with whether their primary care provider (PCP) type is a physician, NP, or PA. In this national retrospective cohort study, we use 2012-2013 national Veterans Administration (VA) electronic health record data from 374 223 veterans to examine whether PCP type is associated with patient, clinic, and state-level factors representing medical and social complexity, adjusting for all variables simultaneously using a generalized logit model. Results indicate that patients with physician PCPs are modestly more medically complex than those with NP or PA PCPs. For the group having a Diagnostic Cost Group (DCG) score >2.0 compared with the group having DCG <0.5, odds of having an NP or a PA were lower than for having a physician PCP (NP odds ratio [OR] = 0.83, 95% confidence interval [CI]: 0.79-0.88; PA OR = 0.85, CI: 0.80-0.89). Social complexity is not consistently associated with PCP type. Overall, we found minor differences in provider type assignment. This study improves on previous work by using a large national dataset that accurately ascribes the work of NPs and PAs, analyzing at the patient level, analyzing NPs and PAs separately, and addressing social as well as medical complexity. This is a requisite step toward studies that compare patient outcomes by provider type.
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Affiliation(s)
| | | | - Valerie A Smith
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sandra Woolson
- 2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - David Edelman
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Cristina C Hendrix
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
| | | | | | - George L Jackson
- 1 Duke University, Durham, NC, USA.,2 Durham Veterans Affairs Medical Center, Durham, NC, USA
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Fleming NS, da Graca B, Ogola GO, Culler SD, Austin J, McConnell P, McCorkle R, Aponte P, Massey M, Fullerton C. Costs of Transforming Established Primary Care Practices to Patient-Centered Medical Homes (PCMHs). J Am Board Fam Med 2017; 30:460-471. [PMID: 28720627 PMCID: PMC5939952 DOI: 10.3122/jabfm.2017.04.170039] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/23/2017] [Accepted: 03/28/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The patient-centered medical home (PCMH) shows promise for improving care and reducing costs. We sought to reduce the uncertainty regarding the time and cost of PCMH transformation by quantifying the direct costs of transforming 57 practices in a medical group to National Committee for Quality Assurance (NCQA)-recognized Level III PCMHs. METHODS We conducted structured interviews with corporate leaders, and with physicians, practice administrators, and office managers from a representative sample of practices regarding time spent on PCMH transformation and NCQA application, and related purchases. We then developed and sent a survey to all primary care practices (practice-level response rate: initial recognition-44.6%, renewal-35.7%). Direct costs were estimated as time spent multiplied by average hourly wage for the relevant job category, plus observed expenditures. RESULTS We estimated HealthTexas' corporate costs for initial NCQA recognition (2010-2012) at $1,508,503; for renewal (2014-2016), $346,617; the Care Coordination resource costs an additional ongoing $390,790/year. A hypothetical 5-physician HealthTexas practice spent another estimated 239.5 hours ($10,669) obtaining, and 110.5 hours ($4,957) renewing, recognition. CONCLUSION Centralized PCMH support reduces the burden on practices; however, overall time and cost remains substantial, and should be weighed against the mixed evidence regarding PCMH's impact on quality and costs of care.
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Affiliation(s)
- Neil S Fleming
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF).
| | - Briget da Graca
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Gerald O Ogola
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Steven D Culler
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Jessica Austin
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Patrice McConnell
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Russell McCorkle
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Phil Aponte
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Michael Massey
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
| | - Cliff Fullerton
- From the Center for Clinical Effectiveness (NSF, BdG, GOO) and STEEEP Analytics (JA), Office of the CQO, Baylor Scott & White Health, Dallas, TX; the Robbins Institute for Health Policy & Leadership, Baylor University, Waco (NSF, BdG); the Rollins School of Public Health, Emory University, Atlanta, GA (SDC); the HealthTexas Provider Network, Dallas (PM, RM, PA, MM); the Baylor Scott & White Quality Alliance, Dallas (MM, CF); and Baylor Scott & White Health, Dallas (CF)
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Nelson K, Hebert P, Fihn SD. Evaluating Patient-Centered Medical Homes. Health Aff (Millwood) 2017; 36:1346. [DOI: 10.1377/hlthaff.2017.0665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Karin Nelson
- Veterans Administration Puget Sound Health Care System Seattle, Washington
| | - Paul Hebert
- Veterans Administration Puget Sound Health Care System Seattle, Washington
| | - Stephan D. Fihn
- Veterans Health Administration Clinical Systems Development and Evaluation Seattle, Washington
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Shippee ND, Finch M, Wholey D. Using Statewide Data on Health Care Quality to Assess the Effect of a Patient-Centered Medical Home Initiative on Quality of Care. Popul Health Manag 2017; 21:148-154. [PMID: 28609248 DOI: 10.1089/pop.2017.0017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Patient-centered medical homes comprise a large portion of modern health care redesign. However, most efforts have reflected rigid, limited models of transformation. In addition, evaluations of their impact on quality of care have relied on data designed for other purposes. Minnesota's Health Care Home (HCH) initiative is a statewide medical home model relying on state-run, adaptive certification and supportive data infrastructure. This longitudinal study leverages a unique statewide system of clinic-reported, patient-level quality data (2010-2013) to assess the effect of being in a HCH clinic on health care quality. Measures included optimal quality (meeting all targets) and average quality (number of targets met) for asthma, vascular, and diabetes care; colorectal cancer screening; depression follow-up; and depression remission. Depending on measure and year, the analytic sample included 246,023 - 3,335,994 child and adult patients in 404-651 clinics. Using endogenous treatment effects models to address endogeneity, and including patient- and clinic-level covariates and clinic-level selection bias corrections, the authors produced potential outcomes means and average treatment effects (ATEs). HCH patients received better quality versus non-HCH patients for most outcomes. For example, the adjusted rate receiving optimal diabetes care was 453.7/1000 adult HCH patients versus 327.2/1000 non-HCH adult patients (ATE = 126.5; P < .001). By contrast, depression remission showed no HCH-related benefit. Findings on average care quality generally echoed optimal care findings. These findings indicate the usefulness of statewide quality data and support the effectiveness of adaptive, state-run medical home programs. Additional integration of services may be needed for mental health conditions.
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Affiliation(s)
- Nathan D Shippee
- 1 Division of Health Policy and Management, University of Minnesota , Minneapolis, Minnesota
| | | | - Douglas Wholey
- 1 Division of Health Policy and Management, University of Minnesota , Minneapolis, Minnesota
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Randall I, Mohr DC, Maynard C. VHA Patient-Centered Medical Home Associated With Lower Rate of Hospitalizations and Specialty Care Among Veterans With Posttraumatic Stress Disorder. J Healthc Qual 2017; 39:168-176. [PMID: 28481843 DOI: 10.1111/jhq.12092] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Veterans Health Administration (VHA) implemented a patient-centered medical home (PCMH) model, termed Patient Aligned Care Teams (PACT), in 2010. We assessed the association between PACT and the use of health services among U.S. veterans with posttraumatic stress disorder (PTSD). METHODS VHA clinical and administrative data were obtained for the pre-PACT period of April 1, 2009 to March 31, 2010 and post-PACT period of June 1, 2011 to May 31, 2012. Outcomes included hospitalizations, primary, specialty and mental health visits, and emergency department and urgent care visits. We utilized negative binomial regression and extended estimating equation models for the full sample. The analysis contained 696,379 unique veterans in both pre- and post-PACT periods. We estimated the linear incremental effect of PACT on utilization outcomes. RESULTS PACT were associated with a decrease in hospitalizations (incremental effect [IE]: -0.02; 95% confidence interval [CI]: -0.03, -0.01), a decrease in specialty care visits (IE: -0.45; 95% CI: -0.07, -0.23), and an increase in primary care visits (IE: 0.96; 95% CI: 0.67, 1.25). CONCLUSIONS The period following PACT implementation was associated with a lower rate of hospitalizations and specialty care visits, and a higher rate of primary care visits for veterans with PTSD, indicating enhanced access to primary care.
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Atkins D, Kilbourne AM, Shulkin D. Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration. Annu Rev Public Health 2017; 38:467-487. [DOI: 10.1146/annurev-publhealth-031816-044255] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.
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Affiliation(s)
- David Atkins
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
| | - Amy M. Kilbourne
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan 48109-5624
| | - David Shulkin
- Veterans Health Administration, US Department of Veterans Affairs, Washington, DC 20420; emails: , ,
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Wong ES, Rosland AM, Fihn SD, Nelson KM. Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden. J Gen Intern Med 2016; 31:1467-1474. [PMID: 27503440 PMCID: PMC5130955 DOI: 10.1007/s11606-016-3833-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/27/2016] [Accepted: 07/22/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The patient-centered medical home (PCMH) model has several components to improve care for patients with high comorbidity, including greater access to face-to-face primary care. OBJECTIVE We examined whether high-comorbidity patients had larger increases in primary care provider (PCP) visits attributable to PCMH implementation in a large integrated health system relative to other patients enrolled in primary care. DESIGN, SUBJECTS AND MAIN MEASURES This longitudinal study examined a 1 % random sample of 9.3 million patients enrolled in the Veterans Health Administration (VHA) at any time between 2003 and 2013. Face-to-face visits with PCPs per quarter were identified through VHA administrative data. Comorbidity was measured using the Gagne index and patients with a weighted score of ≥ 2 were defined as high comorbidity. We applied interrupted time-series models to estimate marginal changes in PCP visits attributable to PCMH implementation. Differences in marginal changes were calculated across comorbidity groups (high vs. low). Analyses were stratified by age group to account for Medicare eligibility. KEY RESULTS Among age 65+ patients, PCMH was associated with greater PCP visits starting four and ten quarters following implementation for high- and low-comorbidity patients, respectively. Changes were larger for high-comorbidity patients (eight to 11 greater visits per 1000 patients per quarter). Among patients age < 65, PCMH was associated with greater visits for high-comorbidity patients starting eight quarters following implementation, but fewer visits for low-comorbidity patients in all quarters. The difference in visit changes across groups ranged from 18 to 67 visits per 1000 patients per quarter. CONCLUSIONS Increases in PCP visits attributable to PCMH were greater among patients with higher comorbidity. Health systems implementing PCMH should account for population-level comorbidity burden when planning for PCMH-related changes in PCP utilization.
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Affiliation(s)
- Edwin S Wong
- VA Puget Sound Health Care System, Center for Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA. .,Department of Health Services, University of Washington, Seattle, WA, USA.
| | - Ann-Marie Rosland
- Center for Clinical Management Research, VHA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Stephan D Fihn
- Office of Analytics and Business Intelligence, Veterans Health Administration, Seattle, WA, USA
| | - Karin M Nelson
- VA Puget Sound Health Care System, Center for Veteran-Centered and Value-Driven Care, 1660 S. Columbian Way, MS S-152, Seattle, WA, 98108, USA.,Department of Health Services, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
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Hebert PL, Hernandez SE. Providing Patient-Centered Care to Veterans of All Races: Challenges and Evidence of Success. J Gen Intern Med 2016; 31:1412-1414. [PMID: 27704365 PMCID: PMC5130965 DOI: 10.1007/s11606-016-3866-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Paul L Hebert
- VA HSR&D Center of Innovation for Patient-Centered and Value-Driven Health Care, VA Puget Sound Health Care System, Seattle, WA, USA.
- Department of Health Services, University of Washington School of Public Health, Seattle, WA, USA.
| | - Susan E Hernandez
- VA HSR&D Center of Innovation for Patient-Centered and Value-Driven Health Care, VA Puget Sound Health Care System, Seattle, WA, USA
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Basu S, Phillips RS, Song Z, Landon BE, Bitton A. Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model. Ann Fam Med 2016; 14:404-14. [PMID: 27621156 PMCID: PMC5394379 DOI: 10.1370/afm.1960] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2016] [Accepted: 05/04/2016] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives. METHODS We estimated practices' changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours. RESULTS Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (-$53,500, 95% CI, -$69,700 to -$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased. CONCLUSIONS PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding.
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Affiliation(s)
- Sanjay Basu
- Department of Medicine, Stanford University, Stanford, California Center for Primary Care, Harvard Medical School, Boston, Massachusetts
| | - Russell S Phillips
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Zirui Song
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Bruce E Landon
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Asaf Bitton
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts Division of General Medicine, Brigham and Women's Hospital, Boston, Massachusetts Ariadne Labs, Brigham and Women's Hospital, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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