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Experimental evidence on the role of shared protocols as coordination device on clinical best practices. Sci Rep 2024; 14:9363. [PMID: 38654112 DOI: 10.1038/s41598-024-60186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 04/19/2024] [Indexed: 04/25/2024] Open
Abstract
Our experiment assesses the level of coordination on clinical best practice among physicians and investigates whether the release of guidelines helps in supporting coordination. Based on three clinical vignettes using current national guidelines, physicians evaluate the appropriateness of each of the proposed courses of action. Afterwards, physicians are allowed to ask which action corresponds to national guidelines and change their ratings, if desired. On average, slightly more than half of the sample coordinated on appropriateness evaluations. Empirical analysis indicates that several organizational and individual variables influence the level of coordination. Additionally, the release of national guidelines improved both the level of conformity and coordination. Our findings suggest changes in implementation practices to increase the impact of these shared protocols in the health field.
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[Interlevel incident management: The experience of a primary care district]. Semergen 2024; 50:102179. [PMID: 38301400 DOI: 10.1016/j.semerg.2023.102179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 02/03/2024]
Abstract
AIM Determine the prevalence and define the profile of interlevel incidences (ININ) between primary care (PC) and hospital (HC). DESIGN Multicenter cross-sectional descriptive study. SITE: Primary care. PARTICIPANTS Professionals from a Health District and its reference hospitals. INTERVENTIONS ININ are errors in communication between PC and HC professionals derived from administrative, pharmaceutical or clinical procedures not resolved during the formal interlevel communication processes, which requires a coordinated and validated response from the health care directions to not overload the family physician. MAIN MEASUREMENTS ININ by category, hospital services and health centers, total and validated, relative to the total number of referrals, and the reason for the ININ. RESULTS We detected 2011 ININs (3.36%) among the 59.859 referrals, although only 1684 were validated (83.7%). Most were administrative (59.5%), followed by pharmaceutical (24.2%), clinical (10.2%) and reverse (6.1%). 41.3% of the clinical ININs were grouped around 5 hospital specialties, and 45.9% in 5 health centers. The main reasons for clinical ININ were non-prescription of the recommended pharmacological treatment in outpatient clinics or on hospital discharge (27.3%), request for referral to another hospital specialist (27.9%), or request to referral in person to patients who had already been referred by teleconsultation (17.8%). CONCLUSIONS 3.36% of interlevel referrals are accompanied by incidents and 83.7% are validated and processed. It is necessary to develop ININ management tools to guarantee safe healthcare and debureaucratize PC.
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Value-based payment models and management of newly diagnosed prostate cancer. Cancer Med 2023; 13:e6810. [PMID: 38146905 PMCID: PMC10807592 DOI: 10.1002/cam4.6810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 12/27/2023] Open
Abstract
OBJECTIVE To examine the effect of urologist participation in value-based payment models on the initial management of men with newly diagnosed prostate cancer. METHODS Medicare beneficiaries with prostate cancer diagnosed between 2017 and 2019, with 1 year of follow-up, were assigned to their primary urologist, each of whom was then aligned to a value-based payment model (the merit-based incentive payment system [MIPS], accountable care organization [ACO] without financial risk, and ACO with risk). Multivariable mixed-effects logistic regression was used to measure the association between payment model participation and treatment of prostate cancer. Additional models estimated the effects of payment model participation on use of treatment in men with very high risk (i.e., >75%) of non-cancer mortality within 10 years of diagnosis (i.e., a group of men for whom treatment is generally not recommended) and price-standardized prostate cancer spending in the 12 months after diagnosis. RESULTS Treatment did not vary by payment model, both overall (MIPS-67% [95% CI 66%-68%], ACOs without risk-66% [95% CI 66%-68%], ACOs with risk-66% [95% CI 64%-68%]). Similarly, treatment did not vary among men with very high risk of non-cancer mortality by payment model (MIPS-52% [95% CI 50%-55%], ACOs without risk-52% [95% CI 50%-55%], ACOs with risk-51% [95% CI 45%-56%]). Adjusted spending was similar across payment models (MIPS-$16,501 [95% CI $16,222-$16,780], ACOs without risk-$16,140 [95% CI $15,852-$16,429], ACOs with risk-$16,117 [95% CI $15,585-$16,649]). CONCLUSIONS How urologists participate in value-based payment models is not associated with treatment, potential overtreatment, and prostate cancer spending in men with newly diagnosed disease.
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Patient engagement in interprofessional team-based chronic disease management: A qualitative description of a Canadian program. PATIENT EDUCATION AND COUNSELING 2023; 114:107836. [PMID: 37336085 DOI: 10.1016/j.pec.2023.107836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 06/21/2023]
Abstract
OBJECTIVE To explore how patients with chronic obstructive pulmonary disease (COPD) perceive their engagement and roles within an interdisciplinary team-based care model. METHODS A single intrinsic case study was used. Focus group participants were recruited from the Best Care COPD program across nine sites. Transcripts from patient focus groups were supplemented by healthcare provider focus group transcripts and thematically analysed. RESULTS The majority of patients viewed themselves as having an inherent or central role on the team, which was corroborated by healthcare providers. Both positive (e.g., a desire to learn) and negative drivers (e.g., fear of inadequate care without self-advocacy) of active engagement were identified, for which patient-led communication was key. Components of the interdisciplinary team-based care model, including provider coordination and action planning, enabled positively driven active engagement and increased self-management. CONCLUSION Although patients had heterogenous perspectives about engagement, most patients viewed themselves as, and were satisfied with, having a central role in their care. Active and passive engagement preferences were influenced by personal motivations and past experiences, amongst other factors. PRACTICE IMPLICATIONS This study demonstrates how interdisciplinary chronic disease management programs can support patient engagement. Clarity of provider expectations, and communication about patients' roles and preferences, are recommended.
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The study protocol to evaluate implementation of the transitional care model in four U.S. healthcare systems during the Covid-19 pandemic. Arch Gerontol Geriatr 2023; 108:104944. [PMID: 36709563 PMCID: PMC9873366 DOI: 10.1016/j.archger.2023.104944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/10/2023] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
This study protocol describes the conceptual framework, design, and methods being employed to evaluate the implementation of the Transitional Care Model (TCM) as part of a randomized controlled trial. The trial, designed to examine the health and cost outcomes of at-risk hospitalized older adults, is being conducted in the context of the COVID-19 pandemic. This parallel study is guided by the Practical, Robust, Implementation and Sustainability Model (PRISM) and uses a fixed, mixed methods convergent parallel design to identify challenges encountered by participating hospitals and post-acute and community-based providers that impact the implementation of the TCM with fidelity, strategies implemented to address those challenges and the relationships between challenges, strategies, and rates of fidelity to TCM's core components over time. Prior to the study's launch and throughout its implementation, qualitative and quantitative data related to COVID and non-COVID challenges are being collected via surveys and meetings with healthcare system staff. Strategies implemented to address challenges and fidelity to TCM's core components are also being assessed. Analyses of quantitative (established metrics to evaluate TCM's core components) and qualitative data (barriers and facilitators to implementation) are being conducted independently. These datasets are then merged and interpreted together. General linear and mixed effects modeling using all merged data and patients' socio-demographic and social determinants of health characteristics, will be used to examine relationships between key variables and fidelity rates. Implications of study findings in the context of COVID-19 and future research opportunities are suggested. Trial registration: ClinicalTrials.gov Identifier: NCT04212962.
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Fragmentation of Care and Its Association With Survival and Costs for Patients With Breast Cancer in Colombia. JCO Glob Oncol 2023; 9:e2200393. [PMID: 37167575 PMCID: PMC10497266 DOI: 10.1200/go.22.00393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/21/2023] [Accepted: 03/06/2023] [Indexed: 05/13/2023] Open
Abstract
PURPOSE Breast cancer care requires a multimodal approach and a multidisciplinary team who must work together to obtain good clinical results. The fragmentation of care can affect the breast cancer care; however, it has not been measured in a low-resource setting. The aim of this study was to identify fragmentation of care, the geographic variation of this and its association with 4-year overall survival (OS), and costs of care for patients with breast cancer enrolled in Colombia's contributory health care system. MATERIALS AND METHODS A retrospective cohort study was conducted using administrative databases. Women with breast cancer who were treated from January 1, 2013, to December 31, 2015, were included. Fragmentation of care was the exposure, which was measured by the number of different health care provider institutions (HCPIs) that treated a patient during the first year after diagnosis. Crude mortality rates were estimated, survival functions were calculated using the nonparametric Kaplan-Meier approach, and adjusted hazard ratios (HRs) were estimated using multivariate Cox regression model to identify the association of fragmentation with 4-year OS. The association between fragmentation and costs of care was assessed using a multivariate linear regression model. RESULTS A total of 10,999 patients with breast cancer were identified, and 1,332 deaths were observed. The 4-year crude mortality rate was 31.97 (95% CI, 30.25 to 33.69) per 1,000 person-years for the whole cohort, and the highest rate was in the cohort defined for the fourth quartile of the fragmentation measurement (eight or more HCPIs), 40.94 (95% CI, 36.49 to 45.39). The adjusted HR for 4-year OS was 1.04 (95% CI, 1.01 to 1.07) for each HCPI additional. The cost of care is increased for each additional HCPIs (cost ratio, 1.25; 95% CI, 1.23 to 1.26). CONCLUSION Fragmentation of care decreases overall 4-year OS and increases the costs of care in women with breast cancer for Colombia.
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Medicare beneficiaries with more comprehensive primary care physicians report better primary care. Health Serv Res 2023; 58:264-270. [PMID: 36527443 PMCID: PMC10012239 DOI: 10.1111/1475-6773.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.
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The ambiguity of "we": Perceptions of teaming in dynamic environments and their implications. Soc Sci Med 2023; 320:115678. [PMID: 36682086 DOI: 10.1016/j.socscimed.2023.115678] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 01/04/2023] [Accepted: 01/13/2023] [Indexed: 01/16/2023]
Abstract
In healthcare, organizations increasingly call on clinicians and staff to team up fluidly to deliver integrated services across disciplines and settings. Yet little is known about how clinicians and staff perceive of team membership in healthcare environments where team boundaries are often ambiguous and continually shifting. We draw on the context of primary care in the United States, where fluid multi-disciplinary teamwork is commonly exhorted, to investigate the extent to which clinicians and staff perceive of various roles (e.g., physician, front desk) as members in their teams, and to identify potential implications. Using a survey fielded within 59 clinics (n = 828), we find substantial variation in individuals' perceptions of the roles they consider as team members during an episode of care (e.g., mean team size = 10.60 roles; standard deviation = 5.09). Perceiving more expansive sets of roles as team members exhibits a positive association with performance as measured by care quality (b = 0.02; p < .01) but a curvilinear association with job satisfaction. Separating an individual's perceived core (roles always perceived as part of the team) and periphery (roles sometimes perceived as part of the team), perceiving a larger core is positively associated with performance (b = 0.03 p < .01). In contrast, perceiving a larger periphery is marginally negatively associated with performance (b = -0.02, p < .10). This appears to be driven by divergence from the norm perception of the core, i.e., when individuals attribute to the periphery the roles that are considered by most others to be core. Our findings suggest that individuals viewing the roles they must team with more expansively may generate higher quality output but experience a personal toll. Delivering on the ideal of team-based care in dynamic environments may require helping team members gain clarity about their teammates and implementing policies that attend to job satisfaction as team boundaries shift and expand.
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Stress-testing the resilience of the Austrian healthcare system using agent-based simulation. Nat Commun 2022; 13:4259. [PMID: 35871248 PMCID: PMC9308034 DOI: 10.1038/s41467-022-31766-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/04/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractPatients do not access physicians at random but rather via naturally emerging networks of patient flows between them. As mass quarantines, absences due to sickness, or other shocks thin out these networks, the system might be pushed to a tipping point where it loses its ability to deliver care. Here, we propose a data-driven framework to quantify regional resilience to such shocks via an agent-based model. For each region and medical specialty we construct patient-sharing networks and stress-test these by removing physicians. This allows us to measure regional resilience indicators describing how many physicians can be removed before patients will not be treated anymore. Our model could therefore enable health authorities to rapidly identify bottlenecks in access to care. Here, we show that regions and medical specialties differ substantially in their resilience and that these systemic differences can be related to indicators for individual physicians by quantifying their risk and benefit to the system.
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Transitional care interventions to reduce emergency department visits in older adults: A systematic review. BELITUNG NURSING JOURNAL 2022; 8:187-196. [PMID: 37547112 PMCID: PMC10401376 DOI: 10.33546/bnj.2100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/24/2022] [Accepted: 05/30/2022] [Indexed: 08/08/2023] Open
Abstract
Background Preventable illnesses cause many emergency department visits in older adults, which can be minimized by implementing appropriate transitional care interventions. However, the most effective transitional care strategies for older adults are unknown. Objective To discover and consolidate transitional care interventions that can help older people avoid going to the emergency department. Methods From January 2011 to August 2021, PubMed, The Cochrane Library, CINAHL, Web of Science, ProQuest, and The JAMA Network were used to search. Two authors independently screened and selected papers, assessed the risk of bias, and extracted data into a standardized form in accordance with Cochrane guidelines. For the risk of bias in studies, the RevMan 5.4.1 program was utilized. Results Six randomized controlled trials, four non-randomized controlled trials, and three retrospective investigations were among the 13 studies examined. All studies evaluated emergency department visits but in different periods (ranging from 1-12 months after discharge) and with varying groups of baselines (pre-post intervention and between groups). The multi-component strategies, either pre or postdischarge phase using high-intensity care delivered within six months of discharge, were implemented in transitional care that had been shown to reduce emergency department visits in older adults. Conclusion To prevent emergency department visits by older patients, nurses should arrange for a high-intensity transitional care intervention that involves both pre-and postdischarge interventions. The effectiveness of the intervention in reducing emergency department visits in older adults is difficult to determine due to inter-study heterogeneity and poor methodological quality. There is a need for more evidence-based research with consistent and trustworthy effect assessments. PROSPERO registration number CRD42021261326.
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Beyond patient-sharing: Comparing physician- and patient-induced networks. Health Care Manag Sci 2022; 25:498-514. [PMID: 35650460 PMCID: PMC9474566 DOI: 10.1007/s10729-022-09595-3] [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] [Received: 10/10/2020] [Accepted: 03/29/2022] [Indexed: 11/04/2022]
Abstract
The sharing of patients reflects collaborative relationships between various healthcare providers. Patient-sharing in the outpatient sector is influenced by both physicians' activities and patients' preferences. Consequently, a patient-sharing network arises from two distinct mechanisms: the initiative of the physicians on the one hand, and that of the patients on the other. We draw upon medical claims data to study the structure of one patient-sharing network by differentiating between these two mechanisms. Owing to the institutional requirements of certain healthcare systems rather following the Bismarck model, we explore different triadic patterns between general practitioners and medical specialists by applying exponential random graph models. Our findings imply deviation from institutional expectations and reveal structural realities visible in both networks.
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Team Relationships and Performance: Evidence from Healthcare Referral Networks. MANAGEMENT SCIENCE 2022; 68:3175-3973. [PMID: 35875601 PMCID: PMC9307056 DOI: 10.1287/mnsc.2021.4091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
We examine the teams that emerge when a primary care physician (PCP) refers patients to specialists. When PCPs concentrate their specialist referrals-for instance, by sending their cardiology patients to fewer distinct cardiologists-repeat interactions between PCPs and specialists are encouraged. Repeated interactions provide more opportunities and incentives to develop productive team relationships. Using data from the Massachusetts All Payer Claims Database, we construct a new measure of PCP team referral concentration and document that it varies widely across PCPs, even among PCPs in the same organization. Chronically ill patients treated by PCPs with a one standard deviation higher team referral concentration have 4% lower health care utilization on average, with no discernible reduction in quality. We corroborate this finding using a national sample of Medicare claims and show that it holds under various identification strategies that account for observed and unobserved patient and physician characteristics. The results suggest that repeated PCP-specialist interactions improve team performance.
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Effect of Peer Benchmarking on Specialist Electronic Consult Performance in a Los Angeles Safety-Net: a Cluster Randomized Trial. J Gen Intern Med 2022; 37:1400-1407. [PMID: 34505234 PMCID: PMC8428492 DOI: 10.1007/s11606-021-07002-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/24/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Since the advent of COVID-19, accelerated adoption of systems that reduce face-to-face encounters has outpaced training and best practices. Electronic consultations (eConsults), structured communications between PCPs and specialists regarding a case, have been effective in reducing face-to-face specialist encounters. As the health system rapidly adapts to multiple new practices and communication tools, new mechanisms to measure and improve performance in this context are needed. OBJECTIVE To test whether feedback comparing physicians to top performing peers using co-specialists' ratings improves performance. DESIGN Cluster-randomized controlled trial PARTICIPANTS: Eighty facility-specialty clusters and 214 clinicians INTERVENTION: Providers in the feedback arms were sent messages that announced their membership in an elite group of "Top Performers" or provided actionable recommendations with feedback for providers that were "Not Top Performers." MAIN MEASURES The primary outcomes were changes in peer ratings in the following performance dimensions after feedback was received: (1) elicitation of information from primary care practitioners; (2) adherence to institutional clinical guidelines; (3) agreement with peer's medical decision-making; (4) educational value; (5) relationship building. KEY RESULTS Specialists showed significant improvements on 3 of the 5 consultation performance dimensions: medical decision-making (odds ratio 1.52, 95% confidence interval 1.08-2.14, p<.05), educational value (1.86, 1.17-2.96) and relationship building (1.63, 1.13-2.35) (both p<.01). CONCLUSIONS The pandemic has shed light on clinicians' commitment to professionalism and service as we rapidly adapt to changing paradigms. Interventions that appeal to professional norms can help improve the efficacy of new systems of practice. We show that specialists' performance can be measured and improved with feedback using aspirational norms. TRIAL REGISTRATION clinicaltrials.gov NCT03784950.
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Assessing the Association Between Network-based Provider Communities and Patient Mortality in the Medicare Population with Multiple Chronic Conditions. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2022; 2022:369-378. [PMID: 35854755 PMCID: PMC9285180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Understanding the complexity of care delivery and care coordination for patients with multiple chronic conditions is challenging. Network analysis can model the relationship between providers and patients to find factors associated with patient mortality. We constructed a network by connecting the providers through shared patients, which was then partitioned into tightly connected communities using a community detection algorithm. After adjusting for patient characteristics, the odds ratio of death for one standard deviation increase in degree centrality ratio between primary care providers (PCPs) and non-PCPs was 0.95 (0.92-0.98). Our result suggest that the centrality of PCPs may be a modifiable factor for improving care delivery. We demonstrated that network analysis can be used to find higher order features associated with health outcomes in addition to patient-level features.
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Integrating network theory into the study of integrated healthcare. Soc Sci Med 2021; 296:114664. [PMID: 35121369 DOI: 10.1016/j.socscimed.2021.114664] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 12/06/2021] [Accepted: 12/15/2021] [Indexed: 12/13/2022]
Abstract
Healthcare policy in the United States (U.S.) has focused on promoting integrated healthcare to combat fragmentation (e.g., 1993 Health Security Act, 2010 Affordable Care Act). Researchers have responded by studying coordination and developing typologies of integration. Yet, after three decades, research evidence for the benefits of coordination and integration are lacking. We argue that research efforts need to refocus in three ways: (1) use social networks to study relational coordination and integrated healthcare, (2) analyze integrated healthcare at three levels of analysis (micro, meso, macro), and (3) focus on clinical integration as the most proximate impact on patient outcomes. We use examples to illustrate the utility of such refocusing and present avenues for future research.
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Trends in Outpatient Care for Medicare Beneficiaries and Implications for Primary Care, 2000 to 2019. Ann Intern Med 2021; 174:1658-1665. [PMID: 34724406 PMCID: PMC8688292 DOI: 10.7326/m21-1523] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite the central role of primary care in improving health system performance, there are little recent data on how use of primary care and specialists has evolved over time and its implications for the range of care coordination needed in primary care. OBJECTIVE To describe trends in outpatient care delivery and the implications for primary care provider (PCP) care coordination. DESIGN Descriptive, repeated, cross-sectional study using Medicare claims from 2000 to 2019, with direct standardization used to control for changes in beneficiary characteristics over time. SETTING Traditional fee-for-service Medicare. PATIENTS 20% sample of Medicare beneficiaries. MEASUREMENTS Annual counts of outpatient visits and procedures, the number of distinct physicians seen, and the number of other physicians seen by a PCP's assigned Medicare patients. RESULTS The proportion of Medicare beneficiaries with any PCP visit annually only slightly increased from 61.2% in 2000 to 65.7% in 2019. The mean annual number of primary care office visits per beneficiary also changed little from 2000 to 2019 (2.99 to 3.00), although the mean number of PCPs seen increased from 0.89 to 1.21 (36.0% increase). In contrast, the mean annual number of visits to specialists increased 20% from 4.05 to 4.87, whereas the mean number of unique specialists seen increased 34.2% from 1.63 to 2.18. The proportion of beneficiaries seeing 5 or more physicians annually increased from 17.5% to 30.1%. In 2000, a PCP's Medicare patient panel saw a median of 52 other physicians (interquartile range, 23 to 87), increasing to 95 (interquartile range, 40 to 164) in 2019. LIMITATION Data were limited to Medicare beneficiaries and, because of the use of a 20% sample, may underestimate the number of other physicians seen across a PCP's entire panel. CONCLUSION Outpatient care for Medicare beneficiaries has shifted toward more specialist care received from more physicians without increased primary care contact. This represents a substantial expansion of the coordination burden faced by PCPs. PRIMARY FUNDING SOURCE National Institute on Aging.
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Providers' mediating role for medication adherence among cancer survivors. PLoS One 2021; 16:e0260358. [PMID: 34843550 PMCID: PMC8629272 DOI: 10.1371/journal.pone.0260358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
Background We conducted a mediation analysis of the provider team’s role in changes to chronic condition medication adherence among cancer survivors. Methods We used a retrospective, longitudinal cohort design following Medicare beneficiaries from 18-months before through 24-months following cancer diagnosis. We included beneficiaries aged ≥66 years newly diagnosed with breast, colorectal, lung or prostate cancer and using medication for non-insulin anti-diabetics, statins, and/or anti-hypertensives and similar individuals without cancer from Surveillance, Epidemiology, and End Results-Medicare data, 2008–2014. Chronic condition medication adherence was defined as a proportion of days covered ≥ 80%. Provider team structure was measured using two factors capturing the number of providers seen and the historical amount of patient sharing among providers. Linear regressions relying on within-survivor variation were run separately for each cancer site, chronic condition, and follow-up period. Results The number of providers and patient sharing among providers increased after cancer diagnosis relative to the non-cancer control group. Changes in provider team complexity explained only small changes in medication adherence. Provider team effects were statistically insignificant in 13 of 17 analytic samples with significant changes in adherence. Statistically significant provider team effects were small in magnitude (<0.5 percentage points). Conclusions Increased complexity in the provider team associated with cancer diagnosis did not lead to meaningful reductions in medication adherence. Interventions aimed at improving chronic condition medication adherence should be targeted based on the type of cancer and chronic condition and focus on other provider, systemic, or patient factors.
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Higher Medicare Expenditures Are Associated With Better Integrated Care as Perceived by Patients. Med Care 2021; 59:565-571. [PMID: 33989247 DOI: 10.1097/mlr.0000000000001558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Integrated care that is continuous, coordinated and patient-centered is vital for Medicare beneficiaries, but its relationship to health care expenditures remains unclear. RESEARCH OBJECTIVE This study explores-for the first time-the relationship between integrated care, as measured from the patient's perspective, and health care expenditures. METHODS Subjects include a sample of continuously eligible fee-for-service Medicare beneficiaries (n=8807) in 2015. Analyses draw on 7 previously validated measures of patient-perceived integrated care from the 2015 Medicare Current Beneficiary Survey. These data are combined with 2015 administrative utilization data that measure health care expenditures. Relationships between patient-perceived integrated care and costs are assessed using generalized linear models with comprehensive control measures. RESULTS Patients who perceive more integrated care have higher expenditures for many, but not all, cost categories examined. Aspects of integrated care pertaining to primary provider and specialist care are associated with higher costs in several areas (particularly inpatient costs associated with specialist knowledge of the patient). Office staff members' knowledge of the patient's medical history is associated with lower home health costs. CONCLUSIONS Patients who experience their care as more integrated may have higher expenditures on average. Thoughtful policy choices, further research, and innovations that enable patients to perceive integrated care at lower or neutral cost are needed.
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Abstract
BACKGROUND Previous studies have suggested that highly fragmented ambulatory care increases the risk of subsequent hospitalization, but those studies used claims only and were not able to adjust for many clinical potential confounders. OBJECTIVE The objective of this study was to determine the association between fragmented ambulatory care and subsequent hospitalization, adjusting for demographics, medical conditions, medications, health behaviors, psychosocial variables, and physiological variables. DESIGN Longitudinal analysis of data (2003-2016) from the nationwide REasons for Geographic And Racial Differences in Stroke (REGARDS) study, linked to Medicare fee-for-service claims. SUBJECTS A total of 12,693 Medicare beneficiaries 65 years and older from the REGARDS study who had at least 4 ambulatory visits in the first year of observation and did not have a hospitalization in the prior year. MEASURES We defined high fragmentation as a reversed Bice-Boxerman score above the 75th percentile. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and incident hospitalization in the 3 months following each exposure period. RESULTS The mean age was 70.4 years; 54% were women, and 33% were African American. During the first year of observation, participants with high fragmentation had a median of 8 ambulatory visits with 6 providers, whereas participants with low fragmentation had a median of 7 visits with 3 providers. Over 11.8 years of follow-up, 6947 participants (55%) had a hospitalization. High fragmentation was associated with an increased hazard of hospitalization (adjusted hazard ratio=1.18; 95% confidence interval: 1.12, 1.24). CONCLUSION Highly fragmented ambulatory care is an independent risk factor for hospitalization.
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Healthcare Fragmentation and Incident Acute Coronary Heart Disease Events: a Cohort Study. J Gen Intern Med 2021; 36:422-429. [PMID: 33140281 PMCID: PMC7878592 DOI: 10.1007/s11606-020-06305-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 10/07/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Highly fragmented ambulatory care (i.e., care spread across many providers without a dominant provider) has been associated with excess tests, procedures, emergency department visits, and hospitalizations. Whether fragmented care is associated with worse health outcomes, or whether any association varies with health status, is unclear. OBJECTIVE To determine whether fragmented care is associated with the risk of incident coronary heart disease (CHD) events, overall and stratified by self-rated general health. DESIGN AND PARTICIPANTS We conducted a secondary analysis of the nationwide prospective Reasons for Geographic and Racial Differences in Stroke (REGARDS) cohort study (2003-2016). We included participants who were ≥ 65 years old, had linked Medicare fee-for-service claims, and had no history of CHD (N = 10,556). MAIN MEASURES We measured fragmentation with the reversed Bice-Boxerman Index. We used Cox proportional hazards models to determine the association between fragmentation as a time-varying exposure and adjudicated incident CHD events in the 3 months following each exposure period. KEY RESULTS The mean age was 70 years; 57% were women, and 34% were African-American. Over 11.8 years of follow-up, 569 participants had CHD events. Overall, the adjusted hazard ratio (HR) for the association between high fragmentation and incident CHD events was 1.14 (95% confidence interval (CI) 0.92, 1.39). Among those with very good or good self-rated health, high fragmentation was associated with an increased hazard of CHD events (adjusted HR 1.35; 95% CI 1.06, 1.73; p = 0.01). Among those with fair or poor self-rated health, high fragmentation was associated with a trend toward a decreased hazard of CHD events (adjusted HR 0.54; 95% CI 0.29, 1.01; p = 0.052). There was no association among those with excellent self-rated health. CONCLUSION High fragmentation was associated with an increased independent risk of incident CHD events among those with very good or good self-rated health.
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Medicare Patient Referral Networks to Female Pelvic Medicine and Reconstructive Surgeons Across the United States. Female Pelvic Med Reconstr Surg 2021; 27:126-130. [PMID: 31274576 DOI: 10.1097/spv.0000000000000751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The source of urogynecology patient referrals remains poorly understood. We used novel methods to identify referral networks to female pelvic medicine and reconstructive surgeons (FPMRS) and to determine factors associated with physician connections. METHODS A retrospective analysis of Centers for Medicare and Medicaid Services data with physician sharing relationships spanning 180 days during 2015 was performed. All patients studied were Medicare beneficiaries. Provider patient-sharing networks were modeled using social network analytics. To visualize the resulting flow of patients from referring providers to FPMRS, we encoded the node and edge data and mapped the data to a map of the United States. RESULTS We studied 206,568 Medicare beneficiaries who were seen by 618 different board-certified FPMRS. Internal medicine physicians followed by nurse practitioners referred the most patients to FPMRS. Over half of referrals were made locally, with patients traveling less than 5 miles from the referring provider to the female pelvic surgeon. The median number of incoming Medicare patient referrals per FPMRS provider was 15 (interquartile range, 12-20) over a 6-month period. The high modularity of the referral network indicates that most providers refer their patients to a few female pelvic surgeons. CONCLUSIONS Medicare patient referrals to FPMRS are primarily and proportionally the highest from local internal medicine physicians.
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Dispersion in the hospital network of shared patients is associated with less efficient care. Health Care Manage Rev 2020; 47:88-99. [PMID: 33298805 DOI: 10.1097/hmr.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND There is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood. PURPOSE We examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination. METHODOLOGY/APPROACH We used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates. RESULTS In multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes. CONCLUSION Dispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care. PRACTICE IMPLICATIONS Hospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.
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Abstract
OBJECTIVE Examine care integration-efforts to unify disparate parts of health care organizations to generate synergy across activities occurring within and between them-to understand whether and at which organizational level health systems impact care quality and staff experience. DATA SOURCES Surveys administered to one practice manager (56/59) and up to 26 staff (828/1360) in 59 practice sites within 24 physician organizations within 17 health systems in four states (2017-2019). STUDY DESIGN We developed manager and staff surveys to collect data on organizational, social, and clinical process integration, at four organizational levels: practice site, physician organization, health system, and outside health systems. We analyzed data using descriptive statistics and regression. PRINCIPAL FINDINGS Managers and staff perceived opportunity for improvement across most types of care integration and organizational levels. Managers/staff perceived little variation in care integration across health systems. They perceived better care integration within practice sites than within physician organizations, health systems, and outside health systems-up to 38 percentage points (pp) lower (P < .001) outside health systems compared to within practice sites. Of nine clinical process integration measures, one standard deviation (SD) (7.2-pp) increase in use of evidence-based care related to 6.4-pp and 8.9-pp increases in perceived quality of care by practice sites and health systems, respectively, and a 4.5-pp increase in staff job satisfaction; one SD (9.7-pp) increase in integration of social services and community resources related to a 7.0-pp increase in perceived quality of care by health systems; one SD (6.9-pp) increase in patient engagement related to a 6.4-pp increase in job satisfaction and a 4.6-pp decrease in burnout; and one SD (10.6-pp) increase in integration of diabetic eye examinations related to a 5.5-pp increase in job satisfaction (all P < .05). CONCLUSIONS Measures of clinical process integration related to higher staff ratings of quality and experience. Action is needed to improve care integration within and outside health systems.
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The impact of sampling patients on measuring physician patient-sharing networks using Medicare data. Health Serv Res 2020; 56:323-333. [PMID: 33090491 PMCID: PMC7968944 DOI: 10.1111/1475-6773.13568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To investigate the impact of sampling patients on descriptive characteristics of physician patient-sharing networks. DATA SOURCES Medicare claims data from 10 hospital referral regions (HRRs) in the United States in 2010. STUDY DESIGN We form a sampling frame consisting of the full cohort of patients (Medicare enrollees) with claims in the 2010 calendar year from the selected HRRs. For each sampling fraction, we form samples of patients from which a physician ("patient-sharing") network is constructed in which an edge between two physicians depicts that at least one patient in the sample encountered both of those physicians. The network is summarized using 18 network measures. For each network measure and sampling fraction, we compare the values determined from the sample and the full cohort of patients. Finally, we assess the sampling fraction that is needed to measure each network measure to specified levels of accuracy. DATA COLLECTION/EXTRACTION METHODS We utilized administrative claims from the traditional (fee-for-service) Medicare. PRINCIPAL FINDINGS We found that measures of physician degree (the number of ties to other physicians) in the network and physician centrality (importance or prominence in the network) are learned quickly in the sense that a small sampling fraction suffices to accurately compute the measure. At the network level, network density (the proportion of possible edges that are present) was learned quickly while measures based on more complex configurations (subnetworks involving multiple actors) are learned relatively slowly with relative rates of learning depending on network size (the number of nodes). CONCLUSIONS The sampling fraction applied to Medicare patients has a highly heterogeneous effect across different network measures on the extent to which sample-based network measures resemble those evaluated using the full cohort. Even random sampling of patients may yield physician networks that distort descriptive features of the network based on the full cohort, potentially resulting in biased results.
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A method for measuring the effect of certified electronic health record technology on childhood immunization status scores among Medicaid managed care network providers. J Biomed Inform 2020; 110:103567. [PMID: 32927058 PMCID: PMC7486207 DOI: 10.1016/j.jbi.2020.103567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 08/05/2020] [Accepted: 09/07/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To provide a methodology for estimating the effect of U.S.-based Certified Electronic Health Records Technology (CEHRT) implemented by primary care physicians (PCPs) on a Healthcare Effectiveness Data and Information Set (HEDIS) measure for childhood immunization delivery. MATERIALS AND METHODS This study integrates multiple health care administrative data sources from 2010 through 2014, analyzed through an interrupted time series design and a hierarchical Bayesian model. We compared managed care physicians using CEHRT to propensity-score matched comparisons from network physicians who did not adopt CEHRT. Inclusion criteria for physicians using CEHRT included attesting to the Childhood Immunization Status clinical quality measure in addition to meeting "Meaningful Use" (MU) during calendar year 2013. We used a first-presence patient attribution approach to develop provider-specific immunization scores. RESULTS We evaluated 147 providers using CEHRT, with 147 propensity-score matched providers selected from a pool of 1253 PCPs practicing in Maryland. The estimate for change in odds of increasing immunization rates due to CEHRT was 1.2 (95% credible set, 0.88-1.73). DISCUSSION We created a method for estimating immunization quality scores using Bayesian modeling. Our approach required linking separate administrative data sets, constructing a propensity-score matched cohort, and using first-presence, claims-based childhood visit information for patient attribution. In the absence of integrated data sets and precise and accurate patient attribution, this is a reusable method for researchers and health system administrators to estimate the impact of health information technology on individual, provider-level, process-based, though outcomes-focused, quality measures. CONCLUSION This research has provided evidence for using Bayesian analysis of propensity-score matched provider populations to estimate the impact of CEHRT on outcomes-based quality measures such as childhood immunization delivery.
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EPA guidance on the quality of mental health services: A systematic meta-review and update of recommendations focusing on care coordination. Eur Psychiatry 2020; 63:e75. [PMID: 32703326 PMCID: PMC7443789 DOI: 10.1192/j.eurpsy.2020.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The quality of mental health services is crucial for the effectiveness and efficiency of mental healthcare systems, symptom reduction, and quality of life improvements in persons with mental illness. In recent years, particularly care coordination (i.e., the integration of care across different providers and treatment settings) has received increased attention and has been put into practice. Thus, we focused on care coordination in this update of a previous European Psychiatric Association (EPA) guidance on the quality of mental health services. METHODS We conducted a systematic meta-review of systematic reviews, meta-analyses, and evidence-based clinical guidelines focusing on care coordination for persons with mental illness in three literature databases. RESULTS We identified 23 relevant documents covering the following topics: case management, integrated care, home treatment, crisis intervention services, transition from inpatient to outpatient care and vice versa, integrating general and mental healthcare, technology in care coordination and self-management, quality indicators, and economic evaluation. Based on the available evidence, we developed 15 recommendations for care coordination in European mental healthcare. CONCLUSIONS Although evidence is limited, some concepts of care coordination seem to improve the effectiveness and efficiency of mental health services and outcomes on patient level. Further evidence is needed to better understand the advantages and disadvantages of different care coordination models.
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How patient-generated health data and patient-reported outcomes affect patient-clinician relationships: A systematic review. Health Informatics J 2020; 26:2689-2706. [PMID: 32567460 PMCID: PMC8986320 DOI: 10.1177/1460458220928184] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Many patients use mobile devices to track health conditions by recording patient-generated health data. However, patients and clinicians may disagree how to use these data. Objective: To systematically review the literature to identify how patient-generated health data and patient-reported outcomes collected outside of clinical settings can affect patient–clinician relationships within surgery and primary care. Methods: Six research databases were queried for publications documenting the effect of patient-generated health data or patient-reported outcomes on patient–clinician relationships. We conducted thematic synthesis of the results of the included publications. Results: Thirteen of the 3204 identified publications were included for synthesis. Three main themes were identified: patient-generated health data supported patient–clinician communication and health awareness, patients desired for their clinicians to be involved with their patient-generated health data, which clinicians had difficulty accommodating, and patient-generated health data platform features may support or hinder patient–clinician collaboration. Conclusion: Patient-generated health data and patient-reported outcomes may improve patient health awareness and communication with clinicians but may negatively affect patient–clinician relationships.
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Care coordination for severe mental health disorders: an analysis of healthcare provider patient-sharing networks and their association with quality of care in a French region. BMC Health Serv Res 2020; 20:548. [PMID: 32552821 PMCID: PMC7298939 DOI: 10.1186/s12913-020-05173-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/31/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For patients with multiple and complex health needs, such as those suffering from mental health disorders, outcomes are determined by the combined actions of the care providers they visit and their interactions. Care coordination is therefore essential. However, little is known on links between hospitals providing psychiatric care and community-based care providers which could serve as a basis for the creation of formal mental care networks supported by recent policies. In this context, we first aimed to identify and characterize existing types of healthcare provider patient-sharing networks for severe mental health disorders in one French region. Second, we aimed to analyse the association between their characteristics and the quality of the care they provide. METHODS Patient flows among healthcare providers involved in treating severe mental health disorders in the Provence-Alpes-Côte-d'Azur region were extracted from the French national health data system, which contains all billing records from the social health insurance. Healthcare provider networks that have developed around public and private non-profit hospitals were identified based on shared patients with other providers (hospitals, community-based psychiatrists, general practitioners and nurses). Hierarchical clustering was conducted to create a typology of the networks. Indicators of quality of care, encompassing multiple complementary dimensions, were calculated across these networks and linked to their characteristics using multivariable methods. RESULTS Three main types of existing healthcare provider networks were identified. They were either networks strongly organized around the main hospital providing psychiatric care; scattered networks involving numerous and diverse healthcare providers; or medically-oriented networks involving mainly physician providers. Few significant associations between the structure and composition of healthcare provider networks and indicators of quality of care were found. CONCLUSIONS Our findings provide a basis to develop explicit structuring of mental care based on pre-existing working relationships but suggest that healthcare providers' patient-sharing patterns were not the main driver of optimal care provision in the context explored. The shift towards a stronger integration of health and social care in the mental health field might impact these results but is currently not observable in the administrative data available for research purpose which should evolve to include social care.
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Physician networks and potentially inappropriate opioid prescriptions. J Addict Dis 2020; 38:301-310. [PMID: 32378481 DOI: 10.1080/10550887.2020.1760655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Opioid overdose is a national health priority and curbing inappropriate prescribing is critical. In 2016, the Centers for Disease Control and Prevention (CDC) issued appropriate prescribing guidelines.Objectives: Examine associations between care networks defined by shared patients and problematic opioid prescribing.Methods: Analysis was at the provider-year level. Social network analysis (SNA) applied to the Medicaid MarketScan® Research Database for the years 2010-2015 identified care communities, each community's level of integration (centralization), and each provider's integration (centrality). Nested multivariable logistic regressions controlling for patient mix and provider specialty simultaneously examined the risk of any (incident) and repeated (prevalent) inappropriate prescribing.Outcomes: Four behaviors defined by the CDC guidelines were examined: (1) more than 90 days continuous supply of high-dose opioid analgesics for chronic pain, (2) overlapping opioid supplies, (3) overlapping opioid and benzodiazepine prescriptions, and (4) prescribing an extended release opioid for an acute pain diagnosis.Results: Provider centrality was associated with reduced incidence of outcome (2) (OR: 0.95) and decreased prevalence of outcomes (1), (2), and (3). However, higher incidence (OR: 1.32) and prevalence (OR: 1.027) of outcome (4) were observed. Conversely, centralization associated with decreased incidence of (1) and (2) and lower prevalence of (1), (2), and (3).Conclusions: Greater provider integration is associated with a lower risk of a provider's patients repeatedly having potentially inappropriate prescription fills; however, the association with a provider having any potentially problematic prescription is more ambiguous.
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It's time to bring human factors to primary care policy and practice. APPLIED ERGONOMICS 2020; 85:103077. [PMID: 32174365 DOI: 10.1016/j.apergo.2020.103077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/04/2020] [Accepted: 02/11/2020] [Indexed: 06/10/2023]
Abstract
Primary health care is a complex, highly personal, and non-linear process. Care is often sub-optimal and professional burnout is high. Interventions intended to improve the situation have largely failed. This is due to a lack of a deep understanding of primary health care. Human Factors approaches and methods will aid in understanding the cognitive, social and technical needs of these specialties, and in designing and testing proposed innovations. In 2012, Ben-Tzion Karsh, Ph.D., conceived a transdisciplinary conference to frame the opportunities for research human factors and industrial engineering in primary care. In 2013, this conference brought together experts in primary care and human factors to outline areas where human factors methods can be applied. The results of this expert consensus panel highlighted four major research areas: Cognitive and social needs, patient engagement, care of community, and integration of care. Work in these areas can inform the design, implementation, and evaluation of innovations in Primary Care. We provide descriptions of these research areas, highlight examples and give suggestions for future research.
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Disconnected: a survey of users and nonusers of telehealth and their use of primary care. J Am Med Inform Assoc 2020; 26:420-428. [PMID: 30865777 DOI: 10.1093/jamia/ocy182] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 11/21/2018] [Accepted: 12/01/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The study sought to assess awareness, perceptions, and value of telehealth in primary care from the perspective of patients. MATERIALS AND METHODS We conducted a cross-sectional, Web-based survey of adults with access to telehealth services who visited healthcare providers for any of the 20 most-commonly seen diagnoses during telehealth visits. Three groups were studied: registered users (RUs) of telehealth had completed a LiveHealth Online (a health plan telehealth service provider) visit, registered nonusers (RNUs) registered for LiveHealth Online but had not conducted a visit, and nonregistered nonusers (NRNUs) completed neither step. RESULTS Of 32 831 patients invited, 3219 (9.8%) responded and 766 met eligibility criteria and completed surveys: 390 (51%) RUs, 117 (15%) RNUs, and 259 (34%) NRNUs. RUs were least likely to have a primary care usual source of care (65.6% vs 78.6% for RNUs vs 80.0% for NRNUs; P < .001). Nearly half (46.8%) of RUs were unable to get an appointment with their doctor, and 34.8% indicated that their doctor's office was closed. Among the 3 groups, RUs were most likely to be employed (89.5% vs 88.9% vs 82.2%; P = .007), have post-high school education (94.4% vs 93.2% vs 86.5%; P = .003), and live in urban areas (81.0% vs 69.2% vs 76.0%; P = .021). CONCLUSIONS Telehealth users reported that they relied on live video for enhanced access and were less connected to primary care than nonusers were. Telehealth may expand service access but risks further fragmentation of care and undermining of the primary care function absent better coordination and information sharing with usual sources of patients' care.
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Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms. Ann Intern Med 2020; 172:S33-S49. [PMID: 31958802 DOI: 10.7326/m19-2407] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The American College of Physicians (ACP) has long advocated for universal access to high-quality health care in the United States. Yet, it is essential that the U.S. health system goes beyond ensuring coverage, efficient delivery systems, and affordability. Fundamental restructuring of payment policies and delivery systems is required to achieve a health care system that puts patients' interests first and supports physicians and their care teams to deliver high-value, patient- and family-centered care. The ACP calls for reform of U.S. payment, delivery, and information technology systems to achieve this vision. The ACP's recommendations include increased investment in primary care; alignment of financial incentives to achieve better patient outcomes, lower costs, reduce inequities in health care, and facilitate team-based care; freeing patients and physicians of inefficient administrative and billing tasks and documentation requirements; and development of health information technologies that enhance the patient-physician relationship.
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Between- and within-person associations between opioid overdose risk and depression, suicidal ideation, pain severity, and pain interference. Drug Alcohol Depend 2020; 206:107734. [PMID: 31775106 PMCID: PMC6980716 DOI: 10.1016/j.drugalcdep.2019.107734] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 11/04/2019] [Accepted: 11/09/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND To better understand overdose (OD) risk and develop tailored overdose risk interventions, we surveyed 234 opioid-using veterans residing in New York City, 2014-2017. Our aim was to better understand how predictors of OD may be associated with physical and mental health challenges, including pain severity and interference, depression and suicidal ideation over time. METHODS Veterans completed monthly assessments of the Overdose Risk Behavior Scale (ORBS), pain severity and interference, suicidal ideation, and depression for up to two years and were assessed an average of 14 times over 611 days. To estimate between-person and within-person associations between time-varying covariates and opioid risk behavior, mixed-effects regression was used on the 145-person subsample of veterans completing the baseline and at least three follow-up assessments. RESULTS The level of each time-varying covariate at the average of study time (between-person effect) was positively related to ORBS for pain severity and interference, suicidal ideation, and depression. Deviations from individuals' personal trajectories (within-person effect) were positively related to ORBS for pain severity and interference, suicidal ideation, and depression. CONCLUSIONS US military veterans endure physical and mental health challenges elevating risk for opioid-related overdose. When pain severity, pain interference, suicidal ideation and depression were higher than usual, opioid risk behavior was higher. Conversely, when these health issues were less of a problem than usual, opioid risk behavior was lower. Assessing the physical and mental health of opioid-using veterans over time may support the development and implementation of interventions to reduce behaviors that increase the likelihood of overdose.
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Dynamics of Physicians' Trust in Fellow Health Care Providers and the Role of Health Information Technology. Med Care Res Rev 2019; 78:338-349. [PMID: 31822195 DOI: 10.1177/1077558719892349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Physicians are expected and incentivized to coordinate patient care with other providers, including nonphysician clinician (NPC) members of care teams, requiring trust. Trust in the context of care teams has not been well-studied; even less is known about how health information technologies (HIT) may modify trust in these relationships. We conducted semistructured interviews with 30 physicians at a Midwestern academic center to examine how physicians determine they can trust NPCs, and how technology modifies these relationships. A majority of physicians base trust in NPCs on cognitive factors such as competence and reliability. Technology enhances trust between physicians and NPCs by supporting evidence-based decision making; it can also erode trust by limiting opportunities for developing familiarity and comfort with fellow providers. Our work has implications for enhancing HIT to promote trust between providers, and for developing more robust measures of trust that can be used in evaluating and improving teamwork within practices.
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Quantification of the resilience of primary care networks by stress testing the health care system. Proc Natl Acad Sci U S A 2019; 116:23930-23935. [PMID: 31712415 PMCID: PMC6883827 DOI: 10.1073/pnas.1904826116] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We shock a full-scale simulation model of a national health care system by locally removing health care providers. We measure resilience of the system in terms of how fast and to what extent it can recover its ability to deliver adequate health services to the population. The model is based on actual regional primary care networks in Austria, where all patients and physicians are represented as anonymized avatars that are calibrated with nationwide data. After removal of a critical fraction of physicians, networks generically undergo a transition from resilient to nonresilient behavior, where it is impossible to maintain coverage for all patients. These “stress tests” allow us to quantify regional health care resilience and identify systemically risky health care providers. There are practically no quantitative tools for understanding how much stress a health care system can absorb before it loses its ability to provide care. We propose to measure the resilience of health care systems with respect to changes in the density of primary care providers. We develop a computational model on a 1-to-1 scale for a countrywide primary care sector based on patient-sharing networks. Nodes represent all primary care providers in a country; links indicate patient flows between them. The removal of providers could cause a cascade of patient displacements, as patients have to find alternative providers. The model is calibrated with nationwide data from Austria that includes almost all primary care contacts over 2 y. We assign 2 properties to every provider: the “CareRank” measures the average number of displacements caused by a provider’s removal (systemic risk) as well as the fraction of patients a provider can absorb when others default (systemic benefit). Below a critical number of providers, large-scale cascades of patient displacements occur, and no more providers can be found in a given region. We quantify regional resilience as the maximum fraction of providers that can be removed before cascading events prevent coverage for all patients within a district. We find considerable regional heterogeneity in the critical transition point from resilient to nonresilient behavior. We demonstrate that health care resilience cannot be quantified by physician density alone but must take into account how networked systems respond and restructure in response to shocks. The approach can identify systemically relevant providers.
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Comparing Shared Patient Networks Across Payers. J Gen Intern Med 2019; 34:2014-2020. [PMID: 30945065 PMCID: PMC6816773 DOI: 10.1007/s11606-019-04978-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 11/21/2018] [Accepted: 02/19/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Measuring care coordination in administrative data facilitates important research to improve care quality. OBJECTIVE To compare shared patient networks constructed from administrative claims data across multiple payers. DESIGN Social network analysis of pooled cross sections of physicians treating prevalent colorectal cancer patients between 2003 and 2013. PARTICIPANTS Surgeons, medical oncologists, and radiation oncologists identified from North Carolina Central Cancer Registry data linked to Medicare claims (N = 1735) and private insurance claims (N = 1321). MAIN MEASURES Provider-level measures included the number of patients treated, the number of providers with whom they share patients (by specialty), the extent of patient sharing with each specialty, and network centrality. Network-level measures included the number of providers and shared patients, the density of shared-patient relationships among providers, and the size and composition of clusters of providers with a high level of patient sharing. RESULTS For 24.5% of providers, total patient volume rank differed by at least one quintile group between payers. Medicare claims missed 14.6% of all shared patient relationships between providers, but captured a greater number of patient-sharing relationships per provider compared with the private insurance database, even after controlling for the total number of patients (27.242 vs 26.044, p < 0.001). Providers in the private network shared a higher fraction of patients with other providers (0.226 vs 0.127, p < 0.001) compared to the Medicare network. Clustering coefficients for providers, weighted betweenness, and eigenvector centrality varied greatly across payers. Network differences led to some clusters of providers that existed in the combined network not being detected in Medicare alone. CONCLUSION Many features of shared patient networks constructed from a single-payer database differed from similar networks constructed from other payers' data. Depending on a study's goals, shortcomings of single-payer networks should be considered when using claims data to draw conclusions about provider behavior.
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Secure Provider-to-Provider Communication With Electronic Health Record Messaging: An Educational Outreach Study. J Healthc Qual 2019; 40:283-291. [PMID: 29280777 DOI: 10.1097/jhq.0000000000000115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION With increasing electronic health record (EHR) use, providers are talking less with one another. Now, many rely on EHRs, informal emails, or texts, introducing fragmentation and new data security challenges with new communication strategies. We aimed to examine the impact of a physician champion educational outreach intervention to promote electronic provider-to-provider communication in a large academic multispecialty group. METHODS Physician champions provided educational outreach to 16 academic departments, using 10-minute case-based presentations. Online surveys assessed communication preferences and practices. Electronic health record queries counted EHR messaging use before and after intervention. Descriptive statistics compared responses by specialty (z-test). Paired responses with pre-post data were compared using chi-square tests. Time series analysis assessed EHR messaging rates before intervention versus after intervention. RESULTS Five hundred seventeen providers responded to the postoutreach survey. Eighty-six percent were familiar with EHR messaging tool and 78% knew how to use it after intervention. Among practitioner groups, Family Medicine preferred EHR messaging the most (62%). Groups who declined outreach least preferred it (26%). Among 88 respondents with paired pre-post intervention surveys, familiarity rose (79-96%), and self-reported use increased (66-88%). CONCLUSIONS Physician champion educational outreach increased the use of the secure provider-to-provider EHR messaging tool.
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Abstract
As health care delivery moves toward more complex, team-based systems, the topic of medical teamwork has gained considerable attention and study across disciplines. This systematic review integrates empirical research on teamwork and health care to identify broad trends. We identified and coded 1,818 relevant, English, and peer-reviewed journal articles using a teamwork processes rubric. Several themes emerged. The health care teamwork literature has grown substantially over the past 20 years. Approximately half of the studies were descriptive (rather than interventional or psychometric); the majority relied on quantitative methods. Health care teamwork was also studied in thematically distinct manners. Interpersonal processes were most commonly studied across fields. Of all disciplines, medicine focused most on transition processes, whereas those from team science centered more highly on action processes. There were also finer grained disciplinary differences in content areas of communication and collaboration. Interprofessional journals represent a potential area for interdisciplinary efforts. Implications and future directions are discussed.
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Primary Care Physicians' Perceived Barriers to Nephrology Referral and Co-management of Patients with CKD: a Qualitative Study. J Gen Intern Med 2019; 34:1228-1235. [PMID: 30993634 PMCID: PMC6614220 DOI: 10.1007/s11606-019-04975-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 12/11/2018] [Accepted: 02/20/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Effective co-management of patients with chronic kidney disease (CKD) between primary care physicians (PCPs) and nephrologists is increasingly recognized as a key strategy to ensure the delivery of efficient and high-quality CKD care. However, the co-management of patients with CKD remains suboptimal. OBJECTIVE We aimed to identify PCPs' perceptions of key barriers and facilitators to effective co-management of patients with CKD at the PCP-nephrology interface. STUDY DESIGN Qualitative study SETTING AND PARTICIPANTS: Community-based PCPs in four US cities: Baltimore, MD; St. Louis, MO; Raleigh, NC; and San Francisco, CA APPROACH: We conducted four focus groups of PCPs. Two members of the research team coded transcribed audio-recorded interviews and identified major themes. KEY RESULTS Most of the 32 PCPs (59% internists and 41% family physicians) had been in practice for > 10 years (97%), spent ≥ 80% of their time in clinical care (94%), and practiced in private (69%) or multispecialty group practice (16%) settings. PCPs most commonly identified barriers to effective co-management of patients with CKD focused on difficulty developing working partnerships with nephrologists, including (1) lack of timely adequate information exchange (e.g., consult note not received or CKD care plan unclear); (2) unclear roles and responsibilities between PCPs and nephrologists; and (3) limited access to nephrologists (e.g., unable to obtain timely consultations or easily contact nephrologists with concerns). PCPs expressed a desire for "better communication tools" (e.g., shared electronic medical record) and clear CKD care plans to facilitate improved PCP-nephrology collaboration. CONCLUSIONS Interventions facilitating timely adequate information exchange, clear delineation of roles and responsibilities between PCPs and nephrologists, and greater access to specialist advice may improve the co-management of patients with CKD.
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Patients' and Providers' Views on Causes and Consequences of Healthcare Fragmentation in the Ambulatory Setting: a Qualitative Study. J Gen Intern Med 2019; 34:899-907. [PMID: 30783883 PMCID: PMC6544669 DOI: 10.1007/s11606-019-04859-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 11/13/2018] [Accepted: 12/20/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients with chronic conditions routinely see multiple outpatient providers, who may or may not communicate with each other. Gaps in information across providers caring for the same patient can lead to harm for patients. However, the exact causes and consequences of healthcare fragmentation are not understood well enough to design interventions to address them. OBJECTIVE We sought to elicit patients' and providers' views on the causes and consequences of healthcare fragmentation. DESIGN AND PARTICIPANTS We conducted a qualitative study with focus groups of patients and, separately, of providers (attending physicians and nurse practitioners) at an academic hospital-based primary care practice in New York City in June-August 2017. Patient participants were English-speaking adults with ≥ 2 chronic conditions. APPROACH Each focus group lasted 1 h and asked the same two questions: "Why do you think some patients receive care from many different providers and others do not?" and "What do you think happens as a result of patients receiving care from many different providers?" Data collection continued until a point of data saturation was reached. Thematic analysis was used to identify themes and subthemes. KEY RESULTS We conducted 6 focus groups with a total of 46 participants (25 patients and 21 providers). Study participants identified 41 unique causes of fragmentation, which originate from 4 different levels of the healthcare system (patient, provider, healthcare organization, and healthcare environment); most causes were not related to medical need. Participants also identified 24 unique consequences of fragmentation, of which 3 were desirable and 21 were undesirable. CONCLUSIONS The results of this study offer a granular roadmap for how to decrease healthcare fragmentation. The large number and severity of negative consequences (including medical errors, misdiagnosis, increased cost, and provider burnout) underscore the urgent need for interventions to address this problem directly.
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Abstract
Managed care plans often attempt to control health care costs through strategies designed to decrease health care utilization. However, the extent to which the resulting patterns of utilization represent high-quality care (compared to fee-for-service products) remains controversial. The authors sought to compare patterns of ambulatory care (including how diffuse or fragmented the care patterns were) for Medicaid fee-for-service beneficiaries vs. Medicaid managed care beneficiaries. A serial cross-sectional study of adults (≥18 years old) was conducted using statewide Medicaid claims from New York State for calendar years 2010-2013. Beneficiaries were required to be continuously enrolled and have ≥4 ambulatory visits for each year they contributed data, yielding a sample of more than 1 million beneficiaries per year. Beneficiaries were characterized by age, sex, and case mix. For each year, ambulatory care patterns were compared across subgroups of beneficiaries using Poisson models (for numbers of visits and providers) and bounded Tobit models (for fragmentation scores). In 2010, among those who were not dual eligible, managed care beneficiaries had on average fewer visits (10.9 visits vs. 11.4 visits [P < 0.0001]) but more providers (3.8 providers vs. 3.3 providers [P < 0.0001]) and therefore more fragmentation (0.58 vs. 0.51 [P < 0.0001]) than fee-for-service beneficiaries, adjusting for age, sex, and case mix. These patterns persisted throughout the follow-up period and in sensitivity analyses. Less utilization is not necessarily more efficient care; a smaller number of visits spread across a larger number of providers creates more challenges for care coordination.
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Variations in VA and Medicare Use Among Veterans With Diabetes: Impacts on Ambulatory Care Sensitive Conditions Hospitalizations for 2008, 2009, and 2010. Med Care 2019; 57:425-436. [PMID: 31045693 DOI: 10.1097/mlr.0000000000001119] [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
INTRODUCTION VA and Medicare use among older Veterans has been considered fragmented care, however, it may represent access to needed care. METHODS The population studied were Veterans with diabetes, age 66 years and older, dually enrolled in VA and Medicare. DATA SOURCE/STUDY SETTING We conducted a dynamic retrospective cohort study with 2008, 2009, and 2010 as the outcome years (Ambulatory Care Sensitive Conditions Hospitalization (ACSC-H) or not). We analyzed administrative data to identify comorbidities; ambulatory care utilization to identify variations in use before hospitalization. We linked 2007 primary care (PC) survey data to assess if organizational factors were associated with ACSC-H. MEASURES AND ANALYSIS We identified ACSC-Hs using a validated definition. We categorized VA/Medicare use as: single system; dual system: supplemental specialty care use; or primary care use. Using hierarchical logistic regression models, we tested for associations between VA/Medicare use, organizational characteristics, and ACSC-H controlling for patient-level, organizational-level, and area-level characteristics. RESULTS Our analytic population was comprised of 210,726 Medicare-eligible Veterans; more than one quarter had an ACSC-H. We found that single system users had higher odds of ACSC-H compared with dual system specialty supplemental care use (odds ratio, 1.14; 95% confidence interval, 1.09-1.20), and no significant difference between dual-system users. Veterans obtaining care at sites where PC leaders reported greater autonomy (eg, authority over personnel issues) had lower odds of ACSC-H (odds ratio, 0.74; 95% confidence interval, 0.59-0.92). DISCUSSION Our findings suggest that earlier assumptions about VA/Medicare use should be weighed against the possibility that neither VA nor Medicare may address complex Veterans' health needs. Greater PC leader autonomy may allow for tailoring of care to match local clinical contexts.
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Abstract
BACKGROUND More and more Veterans are receiving care from community providers, increasing the need for effective coordination across health systems. For Veterans with chronic obstructive pulmonary disease (COPD), this need is intensified by complex comorbidity patterns that often include multiple providers co-managing patient care. OBJECTIVES We sought to understand how VA providers perceive coordination with community providers for Veterans with COPD. DESIGN Qualitative study of VA providers. METHODS We selected six geographically diverse VA sites and conducted semi-structured telephone interviews with providers practicing in inpatient and/or outpatient settings who care for Veterans with COPD. MAIN MEASURES Interviews focused on communication with community providers about discharge information and clinic management. We analyzed responses according to the principles of conventional content analysis, allowing inductive themes to emerge. KEY RESULTS We interviewed 25 providers during the period of June to October 2017. Qualitative data analysis yielded five themes: (1) VA providers perceive communication challenges between VA and community providers, including difficult, inadequate, and delayed communication; (2) communication is facilitated by personal relationships across health systems; (3) the lack of electronic health record (EHR) interoperability impairs communication, resulting in transmission of unstructured data; (4) poor communication leads to duplicative efforts and wasted resources; and (5) providers frequently rely on patients to communicate about care taking place in the community. CONCLUSIONS VA providers described major challenges in coordinating with community providers, leading to perceptions of delayed, missed, or duplicative care and jeopardizing the overall quality, safety, and efficiency of Veteran care. Our study highlights the need for system-level solutions to support coordination across health systems for Veterans with COPD and may have implications for other conditions that lead to recurrent hospitalization and/or care in the community.
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[Patient-sharing networks : New approaches in the analysis and transformation of geographic variation in healthcare]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 60:1356-1371. [PMID: 29064035 DOI: 10.1007/s00103-017-2641-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The analysis of geographic variations has spurred arguments that area of residence determines access to and quality of healthcare. In this paper we argue that unwarranted geographic variations can be traced back to actions of individual patients and their healthcare providers (doctors, hospitals). These actors interact in a complicated web of shared responsibilities. Designing effective interventions to reduce unwarranted geographic variations may therefore depend on methods to identify these interactions and communities of providers with a shared accountability. In the US, Canada, and Germany, routine data have been used to identify self-organized informal or virtual networks of physicians and hospitals, so-called patient-sharing networks (PSNs). This is an emerging field of analysis. We attempt to provide a brief report on the state of work in progress. It can be shown that variation between PSNs in a given area is effectively greater than variation between regions. While this suggests that reducing unwarranted variation needs to start at the level of PSN, methods to identify PSNs still vary widely. We compare epidemiological approaches and approaches based on graph theory and social network analysis. We also present some preliminary findings of exploratory analyses based on comprehensive claims data of physician practices in Germany. Defining PSNs based on usual provider relationships helps to create distinctive patient populations while PSNs may not be mutually exclusive. Social network analysis, on the other hand, appears better equipped to differentiate between provider communities with stronger and weaker ties; it does not yield distinctive patient populations. To achieve accountability and to support change management, analytic methods to describe PSNs still need refinement. There are first projects in Germany which use PSNs as an intervention platform in order to achieve improved cooperation and reduce unwarranted variation in their care processes.
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Implementation of a care coordination system for chronic diseases. Yeungnam Univ J Med 2019; 36:1-7. [PMID: 31620605 PMCID: PMC6784624 DOI: 10.12701/yujm.2019.00073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/08/2018] [Accepted: 12/18/2018] [Indexed: 11/24/2022] Open
Abstract
The number of people with chronic diseases has been increasing steadily but the indicators for the management of chronic diseases have not improved significantly. To improve the existing chronic disease management system, a new policy will be introduced, which includes the establishment of care plans for hypertension and diabetes patients by primary care physicians and the provision of care coordination services based on these plans. Care coordination refers to a series of activities to assist patients and their families and it has been known to be effective in reducing medical costs and avoiding the unnecessary use of the hospital system by individuals. To offer well-coordinated and high-quality care services, it is necessary to develop a service quality assurance plan, track and manage patients, provide patient support, agree on patient referral and transition, and develop an effective information system. Local governance should be established for chronic disease management, and long-term plans and continuous quality improvement are necessary.
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Coordination of Care Around Surgery for Colon Cancer: Insights From National Patterns of Physician Encounters With Medicare Beneficiaries. J Oncol Pract 2018; 15:e110-e121. [PMID: 30550373 DOI: 10.1200/jop.18.00228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.
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Non–Face-to-Face Chronic Care Management: A Qualitative Study Assessing the Implementation of a New CMS Reimbursement Strategy. Popul Health Manag 2018; 21:454-461. [DOI: 10.1089/pop.2017.0196] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Barriers and Facilitators in Implementing Non-Face-to-Face Chronic Care Management in an Elderly Population with Diabetes: A Qualitative Study of Physician and Health System Perspectives. J Clin Med 2018; 7:jcm7110451. [PMID: 30463310 PMCID: PMC6262419 DOI: 10.3390/jcm7110451] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023] Open
Abstract
The burden of illness related to diabetes and its complications is exceedingly high and growing globally. Systematic approaches to managing chronic care are needed to address the complex nature of the disease, taking into account health system structures. This study presents data collected from interviews with physicians, health system administrators, and other healthcare staff about chronic care management for elderly people with diabetes co-morbid with other chronic conditions in light of new programs intended to reduce barriers by incentivizing care encounters that take place through telephone and electronic communications (non-face-to-face care). Results indicate that health system personnel view non-face-to-face care as potentially providing value for patients and addressing systemic needs, yet challenging to implement in practice. Barriers and facilitators to this approach for managing diabetes and chronic care management for its complications are presented, with consideration to different types of health systems, and recommendations are provided for implementation.
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Improving Care Transitions: An Academic Service Partnership to Achieve Coordination of Care Using Students as Health Coaches. J Nurs Adm 2018; 48:629-635. [PMID: 30407929 DOI: 10.1097/nna.0000000000000696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To avoid penalty through the Hospital Readmission Reduction Program, an academic practice partnership, Health Transitions Alliance, was formed with the local university, resulting in adoption of an innovative transitional care model. Key to the model was a health coach who operationalized transition care to the home setting. Health coaches, interns in their last semester of college, used motivational interviewing to help patients set disease management goals. As a result of this model, the readmission rate for program participants in the initial 7 months was reduced by 72%.
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Validation and Testing of Fast Healthcare Interoperability Resources Standards Compliance: Data Analysis. JMIR Med Inform 2018; 6:e10870. [PMID: 30355549 PMCID: PMC6231749 DOI: 10.2196/10870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/07/2018] [Accepted: 09/29/2018] [Indexed: 11/23/2022] Open
Abstract
Background There is wide recognition that the lack of health data interoperability has significant impacts. Traditionally, health data standards are complex and test-driven methods played important roles in achieving interoperability. The Health Level Seven International (HL7) standard Fast Healthcare Interoperability Resources (FHIR) may be a technical solution that aligns with policy, but systems need to be validated and tested. Objective Our objective is to explore the question of whether or not the regular use of validation and testing tools improves server compliance with the HL7 FHIR specification. Methods We used two independent validation and testing tools, Crucible and Touchstone, and analyzed the usage and result data to determine their impact on server compliance with the HL7 FHIR specification. Results The use of validation and testing tools such as Crucible and Touchstone are strongly correlated with increased compliance and “practice makes perfect.” Frequent and thorough testing has clear implications for health data interoperability. Additional data analysis reveals trends over time with respect to vendors, use cases, and FHIR versions. Conclusions Validation and testing tools can aid in the transition to an interoperable health care infrastructure. Developers that use testing and validation tools tend to produce more compliant FHIR implementations. When it comes to health data interoperability, “practice makes perfect.”
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