Quality of care of Medicare patients with diabetes in a metropolitan fee-for-service primary care integrated delivery system

System-Level Health-Care Integration and the Costs of Cancer Care Across the Disease Continuum

PURPOSE

Policy reforms in the Affordable Care Act encourage health care integration to improve quality and lower costs. We examined the association between system-level integration and longitudinal costs of cancer care.

METHODS

We used linked SEER-Medicare data to identify patients age 66 to 99 years diagnosed with prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, breast, or ovarian cancer from 2007 to 2012. We attributed each patient to one or more phases of care (ie, initial, continuing, and end of life) according to time from diagnosis until death or end of study interval. For each phase, we aggregated all claims with the primary cancer diagnosis and identified patients treated in an integrated delivery network (IDN), as defined by the Becker Hospital Review list of the top 100 most integrated health delivery systems. We then determined if care provided in an IDN was associated with decreased payments across cancers and for each individual cancer by phase and across phases.

RESULTS

We identified 428,300 patients diagnosed with one of 10 common cancers. Overall, there were no differences in phase-based payments between IDNs and non-IDNs. Average adjusted annual payments by phase for IDN versus non-IDNs were as follows: initial, $14,194 versus $14,421, respectively ( P = .672); continuing, $2,051 versus $2,099 ( P = .566); and end of life, $16,257 versus $16,232 ( P = .948). However, in select cancers, we observed lower payments in IDNs. For bladder cancer, payments at the end of life were lower for IDNs ($11,041 v $12,331; P = .008). Of the four cancers with the lowest 5-year survival rates (ie, pancreatic, lung, esophageal, and liver), average expenditures during the initial and continuing-care phases were lower for patients with liver cancer treated in IDNs.

CONCLUSION

For patients with one of 10 common malignancies, treatment in an IDN generally is not associated with lower costs during any phase of cancer care.

Interventions to increase attendance for diabetic retinopathy screening

BACKGROUND

Despite evidence supporting the effectiveness of diabetic retinopathy screening (DRS) in reducing the risk of sight loss, attendance for screening is consistently below recommended levels.

OBJECTIVES

The primary objective of the review was to assess the effectiveness of quality improvement (QI) interventions that seek to increase attendance for DRS in people with type 1 and type 2 diabetes.Secondary objectives were:To use validated taxonomies of QI intervention strategies and behaviour change techniques (BCTs) to code the description of interventions in the included studies and determine whether interventions that include particular QI strategies or component BCTs are more effective in increasing screening attendance;To explore heterogeneity in effect size within and between studies to identify potential explanatory factors for variability in effect size;To explore differential effects in subgroups to provide information on how equity of screening attendance could be improved;To critically appraise and summarise current evidence on the resource use, costs and cost effectiveness.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, Web of Science, ProQuest Family Health, OpenGrey, the ISRCTN, ClinicalTrials.gov, and the WHO ICTRP to identify randomised controlled trials (RCTs) that were designed to improve attendance for DRS or were evaluating general quality improvement (QI) strategies for diabetes care and reported the effect of the intervention on DRS attendance. We searched the resources on 13 February 2017. We did not use any date or language restrictions in the searches.

SELECTION CRITERIA

We included RCTs that compared any QI intervention to usual care or a more intensive (stepped) intervention versus a less intensive intervention.

DATA COLLECTION AND ANALYSIS

We coded the QI strategy using a modification of the taxonomy developed by Cochrane Effective Practice and Organisation of Care (EPOC) and BCTs using the BCT Taxonomy version 1 (BCTTv1). We used Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status, and Social capital (PROGRESS) elements to describe the characteristics of participants in the included studies that could have an impact on equity of access to health services.Two review authors independently extracted data. One review author entered the data into Review Manager 5 and a second review author checked them. Two review authors independently assessed risks of bias in the included studies and extracted data. We rated certainty of evidence using GRADE.

MAIN RESULTS

We included 66 RCTs conducted predominantly (62%) in the USA. Overall we judged the trials to be at low or unclear risk of bias. QI strategies were multifaceted and targeted patients, healthcare professionals or healthcare systems. Fifty-six studies (329,164 participants) compared intervention versus usual care (median duration of follow-up 12 months). Overall, DRS attendance increased by 12% (risk difference (RD) 0.12, 95% confidence interval (CI) 0.10 to 0.14; low-certainty evidence) compared with usual care, with substantial heterogeneity in effect size. Both DRS-targeted (RD 0.17, 95% CI 0.11 to 0.22) and general QI interventions (RD 0.12, 95% CI 0.09 to 0.15) were effective, particularly where baseline DRS attendance was low. All BCT combinations were associated with significant improvements, particularly in those with poor attendance. We found higher effect estimates in subgroup analyses for the BCTs 'goal setting (outcome)' (RD 0.26, 95% CI 0.16 to 0.36) and 'feedback on outcomes of behaviour' (RD 0.22, 95% CI 0.15 to 0.29) in interventions targeting patients, and 'restructuring the social environment' (RD 0.19, 95% CI 0.12 to 0.26) and 'credible source' (RD 0.16, 95% CI 0.08 to 0.24) in interventions targeting healthcare professionals.Ten studies (23,715 participants) compared a more intensive (stepped) intervention versus a less intensive intervention. In these studies DRS attendance increased by 5% (RD 0.05, 95% CI 0.02 to 0.09; moderate-certainty evidence).Fourteen studies reporting any QI intervention compared to usual care included economic outcomes. However, only five of these were full economic evaluations. Overall, we found that there is insufficient evidence to draw robust conclusions about the relative cost effectiveness of the interventions compared to each other or against usual care.With the exception of gender and ethnicity, the characteristics of participants were poorly described in terms of PROGRESS elements. Seventeen studies (25.8%) were conducted in disadvantaged populations. No studies were carried out in low- or middle-income countries.

AUTHORS' CONCLUSIONS

The results of this review provide evidence that QI interventions targeting patients, healthcare professionals or the healthcare system are associated with meaningful improvements in DRS attendance compared to usual care. There was no statistically significant difference between interventions specifically aimed at DRS and those which were part of a general QI strategy for improving diabetes care. This is a significant finding, due to the additional benefits of general QI interventions in terms of improving glycaemic control, vascular risk management and screening for other microvascular complications. It is likely that further (but smaller) improvements in DRS attendance can also be achieved by increasing the intensity of a particular QI component or adding further components.

Association of Delivery System Integration and Outcomes for Major Cancer Surgery

BACKGROUND

Integrated delivery systems (IDSs) are postulated to reduce spending and improve outcomes through successful coordination of care across multiple providers. Nonetheless, the actual impact of IDSs on outcomes for complex multidisciplinary care such as major cancer surgery is largely unknown.

METHODS

Using 2011-2013 Medicare data, this study identified patients who underwent surgical resection for prostate, bladder, esophageal, pancreatic, lung, liver, kidney, colorectal, or ovarian cancer. Rates of readmission, 30-day mortality, surgical complications, failure to rescue, and prolonged hospital stay for cancer surgery were compared between patients receiving care at IDS hospitals and those receiving care at non-IDS hospitals. Generalized estimating equations were used to adjust results by cancer type and patient- and hospital-level characteristics while accounting for clustering of patients within hospitals.

RESULTS

The study identified 380,053 patients who underwent major resection of cancer, with 38% receiving care at an IDS. Outcomes did not differ between IDS and non-IDS hospitals regarding readmission and surgical complication rates, whereas only minor differences were observed for 30-day mortality (3.5% vs 3.2% for IDS; p < 0.001) and prolonged hospital stay (9.9% vs 9.2% for IDS; p < 0.001). However, after adjustment for patient and hospital characteristics, the frequencies of adverse perioperative outcomes were not significantly associated with IDS status.

CONCLUSIONS

The collective findings suggest that local delivery system integration alone does not necessarily have an impact on perioperative outcomes in surgical oncology. Moving forward, stakeholders may need to focus on surgical and oncology-specific methods of care coordination and quality improvement initiatives to improve outcomes for patients undergoing cancer surgery.

Accountability across the Continuum: The Participation of Postacute Care Providers in Accountable Care Organizations

OBJECTIVE

To examine the extent to which accountable care organizations (ACOs) formally incorporate postacute care providers.

DATA SOURCES

The National Survey of ACOs (N = 269, response rate 66 percent).

STUDY DESIGN

We report statistics on ACOs' formal inclusion of postacute care providers and the organizational characteristics and clinical capabilities of ACOs that have postacute care.

PRINCIPAL FINDINGS

Half of ACOs formally include at least one postacute service, with inclusion at higher rates in ACOs with commercial (64 percent) and Medicaid contracts (70 percent) compared to ACOs with Medicare contracts only (45 percent). ACOs that have a formal relationship with a postacute provider are more likely to have advanced transition management, end of life planning, readmission prevention, and care management capabilities.

CONCLUSIONS

Many ACOs have not formally engaged postacute care, which may leave room to improve service integration and care management.

The effectiveness of implementing an electronic health record on diabetes care and outcomes

OBJECTIVE

To assess the impact of electronic health record (EHR) implementation on primary care diabetes care.

DATA SOURCES

Charts were abstracted semi-annually for 14,051 diabetes patients seen in 34 primary care practices in a large, fee-for-service network from January 1, 2005 to December 31, 2010. The study sample was limited to patients aged 40 years or older.

STUDY DESIGN

A naturalistic experiment in which GE Centricity Physician Office-EMR 2005 was rolled out over a staggered 3-year schedule.

DATA COLLECTION

Chart audits were conducted using the AMA/Physician Consortium Adult Diabetes Measure set. The primary outcome was the HealthPartners' "optimal care" measure: HbA1c ≤ 8 percent; LDL cholesterol < 100 mg/dl; blood pressure < 130/80 mmHg; not smoking; and documented aspirin use in patients ≥ 40 years of age.

PRINCIPAL FINDINGS

After adjusting for patient age, sex, and insulin use, patients exposed to the EHR were significantly more likely to receive "optimal care" when compared with unexposed patients (p < .001), with an estimated difference of 9.20 percent (95% CI: 6.08, 12.33) in the final year between exposed patients and patients never exposed. Components of the optimal care bundle showing positive improvement after adjustment were systolic blood pressure <80 mmHg, diastolic blood pressure <130 mmHg, aspirin prescription, and smoking cessation. Among patients exposed to EHR, all process and outcome measures except HbA1c and lipid control showed significant improvement.

CONCLUSION

Implementation of a commercially available EHR in primary care practice may improve diabetes care and clinical outcomes.

The impact of primary care: a focused review

Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as "snowballing" based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.

Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial

Nurses with advanced training-diabetes resource nurses (DRNs)-can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A(1c) level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A(1c) testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A(1c) <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.

Quality of care for diabetes patients using National Health Insurance claims data in Japan

BACKGROUND

Assessment of the quality of care is a key element in current diabetes care. However, the quality of care for diabetes patients in Japan has rarely been reported.

OBJECTIVES

To assess the quality of diabetes care in two communities in Japan by using National Health Insurance claims data.

METHODS

We analysed claim data of 13,650 beneficiaries of National Health Insurance in two communities in Japan from May 2006 to April 2007. Diabetes cases were identified by using a case detection algorism. Our main outcome measures were three process quality indicators: (1) haemoglobin A1c (HbA1c) testing; (2) annual eye examination; and (3) annual nephropathy screening, recommended in the existing clinical guidelines. We calculated the performance rate of each quality indicator and examined the effects of demographic characteristics and co-morbid conditions.

RESULTS

We identified 636 diabetes cases. Of these, 97.0% had at least one HbA1c test, and 69.8% had ≥ 4 tests during the study period. The odds ratios (ORs) for ≥ 4 HbA1c tests were lower in subgroups aged 75-79 (OR 0.58, 95% confidence interval 0.35-0.96), and aged ≥ 80 (OR 0.54, 95% confidence interval 0.32-0.88) compared with the subgroup aged <70 after adjusting for other patient characteristics. The annual rate for eye examinations and nephropathy screenings were 20.8% and 5.8% respectively.

CONCLUSIONS

We found high performance rates for HbA1c testing, while the annual rates for eye examinations and nephropathy screenings were suboptimal. Using administrative data would facilitate more comprehensive assessment of the quality of care in Japan.