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Abstract
This study examines whether Medicare Advantage (MA) enrollees with more chronic conditions were more likely to disenroll when MA enrollment grew rapidly from 2009 to 2019.
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Affiliation(s)
- Eli Raver
- College of Public Health, The Ohio State University, Columbus
| | - Jeah Jung
- College of Public Health, George Mason University, Fairfax, Virginia
| | - Wendy Y. Xu
- College of Public Health, The Ohio State University, Columbus
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Stewart A, Antoniou T, Graves E, Plumptre L, Carusone SC. Health care utilization in medically complex people living with HIV before and after admission to an HIV-specific community facility: a pre-post comparison study. CMAJ Open 2021; 9:E460-E465. [PMID: 33958381 PMCID: PMC8157977 DOI: 10.9778/cmajo.20200024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND People living with HIV and multiple comorbidities have high rates of health service use. This study evaluates system usage before and after admission to a community facility focused on HIV care. METHODS We used Ontario administrative health databases to conduct a pre-post comparison of rates and costs of hospital admissions, emergency department visits, and family physician and home care visits among medically complex people with HIV in the year before and after admission to Casey House, an HIV-specific hospital in Toronto, for all individuals admitted between April 2009 and March 2015. Negative binomial regression was used to compare rates of health care utilization. We used Wilcoxon rank sum tests to compare associated health care costs, standardized to 2015 Canadian dollars. To contextualize our findings, we present rates and costs of health service use among Ontario residents living with HIV. RESULTS During the study period, 268 people living with HIV were admitted to Casey House. Emergency department use declined from 4.6 to 2.5 visits per person-year (p = 0.02) after discharge from Casey House, and hospitalization rates declined from 1.4 to 1.1 admissions per person-year (p = 0.05). Conversely, home care visits increased from 24.3 to 35.6 visits per person-year (p = 0.01) and family physician visits increased from 18.3 to 22.6 visits per person-year (p < 0.001) in the year after discharge. These changes were associated with reduced overall costs to the health care system. The reduction in overall costs was not significant (p = 0.2); however, costs of emergency department visits (p < 0.001) and physician visits (p < 0.001) were significantly less. INTERPRETATION Health care utilization by people with HIV was significantly different before and after admission to a community hospital focused on HIV care. This has implications for health care in other complex patient populations.
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Affiliation(s)
- Ann Stewart
- Department of Family and Community Medicine (Stewart, Antoniou), St. Michael's Hospital, University of Toronto; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital; ICES (Antoniou, Graves, Plumptre); Casey House (Chan Carusone), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Chan Carusone), McMaster University, Hamilton, Ont.
| | - Tony Antoniou
- Department of Family and Community Medicine (Stewart, Antoniou), St. Michael's Hospital, University of Toronto; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital; ICES (Antoniou, Graves, Plumptre); Casey House (Chan Carusone), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Chan Carusone), McMaster University, Hamilton, Ont
| | - Erin Graves
- Department of Family and Community Medicine (Stewart, Antoniou), St. Michael's Hospital, University of Toronto; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital; ICES (Antoniou, Graves, Plumptre); Casey House (Chan Carusone), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Chan Carusone), McMaster University, Hamilton, Ont
| | - Lesley Plumptre
- Department of Family and Community Medicine (Stewart, Antoniou), St. Michael's Hospital, University of Toronto; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital; ICES (Antoniou, Graves, Plumptre); Casey House (Chan Carusone), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Chan Carusone), McMaster University, Hamilton, Ont
| | - Soo Chan Carusone
- Department of Family and Community Medicine (Stewart, Antoniou), St. Michael's Hospital, University of Toronto; Li Ka Shing Knowledge Institute (Antoniou), St. Michael's Hospital; ICES (Antoniou, Graves, Plumptre); Casey House (Chan Carusone), Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Chan Carusone), McMaster University, Hamilton, Ont
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Abstract
IMPORTANCE Medically complex patients are a heterogeneous group that contribute to a substantial proportion of health care costs. Coordinated efforts to improve care and reduce costs for this patient population have had limited success to date. OBJECTIVE To define distinct patient clinical profiles among the most medically complex patients through clinical interpretation of analytically derived patient clusters. DESIGN, SETTING, AND PARTICIPANTS This cohort study analyzed the most medically complex patients within Kaiser Permanente Northern California, a large integrated health care delivery system, based on comorbidity score, prior emergency department admissions, and predicted likelihood of hospitalization, from July 18, 2018, to July 15, 2019. From a starting point of over 5000 clinical variables, we used both clinical judgment and analytic methods to reduce to the 97 most informative covariates. Patients were then grouped using 2 methods (latent class analysis, generalized low-rank models, with k-means clustering). Results were interpreted by a panel of clinical stakeholders to define clinically meaningful patient profiles. MAIN OUTCOMES AND MEASURES Complex patient profiles, 1-year health care utilization, and mortality outcomes by profile. RESULTS The analysis included 104 869 individuals representing 3.3% of the adult population (mean [SD] age, 70.7 [14.5] years; 52.4% women; 39% non-White race/ethnicity). Latent class analysis resulted in a 7-class solution. Stakeholders defined the following complex patient profiles (prevalence): high acuity (9.4%), older patients with cardiovascular complications (15.9%), frail elderly (12.5%), pain management (12.3%), psychiatric illness (12.0%), cancer treatment (7.6%), and less engaged (27%). Patients in these groups had significantly different 1-year mortality rates (ranging from 3.0% for psychiatric illness profile to 23.4% for frail elderly profile; risk ratio, 7.9 [95% CI, 7.1-8.8], P < .001). Repeating the analysis using k-means clustering resulted in qualitatively similar groupings. Each clinical profile suggested a distinct collaborative care strategy to optimize management. CONCLUSIONS AND RELEVANCE The findings suggest that highly medically complex patient populations may be categorized into distinct patient profiles that are amenable to varying strategies for resource allocation and coordinated care interventions.
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Affiliation(s)
- Richard W. Grant
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jodi McCloskey
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Meghan Hatfield
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Connie Uratsu
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - James D. Ralston
- Kaiser Permanente Washington Health Research Institute, Kaiser Permanente Washington, Seattle
| | | | - Chris J. Kennedy
- Division of Research, Kaiser Permanente Northern California, Oakland
- Division of Epidemiology and Biostatistics, University of California, Berkeley, Berkeley
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Clements JM, West BT, Yaker Z, Lauinger B, McCullers D, Haubert J, Tahboub MA, Everett GJ. Disparities in diabetes-related multiple chronic conditions and mortality: The influence of race. Diabetes Res Clin Pract 2020; 159:107984. [PMID: 31846667 PMCID: PMC6959124 DOI: 10.1016/j.diabres.2019.107984] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/21/2019] [Accepted: 12/13/2019] [Indexed: 01/03/2023]
Abstract
AIMS The aims of this study are to confirm disparities in diabetes mortality rates based on race, determine if race predicts combinations of diabetes and multiple chronic conditions (MCC) that are leading causes of death (LCD), and determine if combinations of diabetes plus MCC mediate the relationship between race and mortality. METHODS We performed a retrospective cohort study of 443,932 Medicare beneficiaries in the State of Michigan with type 2 diabetes mellitus and MCC. We applied Cox proportional hazards regression to determine predictors of mortality. We applied multinomial logistic regression to determine predictors of MCC combinations. RESULTS We found that race influences mortality in Medicare beneficiaries with Type 2 diabetes mellitus and MCC. Prior to adjusting for MCC combinations, we observed that Blacks and American Indian/Alaska Natives have increased risk of mortality compared to Whites, while there is no difference in mortality between Hispanics and Whites. Regarding MCC combinations, Black/African American beneficiaries experience increased odds for most MCC combinations while Asian/Pacific Islanders and Hispanics experience lower odds for MCC combinations, compared to Whites. When adjusting for MCC, mortality disparities observed between Whites, Black/African Americans, and American Indians/Alaska Natives persist. CONCLUSIONS Compared to Whites, Black/African Americans in our cohort had increased odds of most MCC combinations, and an increased risk of mortality that persisted even after adjusting for MCC combinations.
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Affiliation(s)
- John M Clements
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States.
| | - Brady T West
- Survey Research Center, Institute for Social Research, University of Michigan-Ann Arbor, United States
| | - Zachary Yaker
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
| | - Breanna Lauinger
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
| | - Deven McCullers
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
| | - James Haubert
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
| | - Mohammad Ali Tahboub
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
| | - Gregory J Everett
- Central Michigan University, College of Medicine, 1280 East Campus Dr., Mount Pleasant, MI 48859, United States
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Majumdar UB, Hunt C, Doupe P, Baum AJ, Heller DJ, Levine EL, Kumar R, Futterman R, Hajat C, Kishore SP. Multiple chronic conditions at a major urban health system: a retrospective cross-sectional analysis of frequencies, costs and comorbidity patterns. BMJ Open 2019; 9:e029340. [PMID: 31619421 PMCID: PMC6797368 DOI: 10.1136/bmjopen-2019-029340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To (1) examine the burden of multiple chronic conditions (MCC) in an urban health system, and (2) propose a methodology to identify subpopulations of interest based on diagnosis groups and costs. DESIGN Retrospective cross-sectional study. SETTING Mount Sinai Health System, set in all five boroughs of New York City, USA. PARTICIPANTS 192 085 adult (18+) plan members of capitated Medicaid contracts between the Healthfirst managed care organisation and the Mount Sinai Health System in the years 2012 to 2014. METHODS We classified adults as having 0, 1, 2, 3, 4 or 5+ chronic conditions from a list of 69 chronic conditions. After summarising the demographics, geography and prevalence of MCC within this population, we then described groups of patients (segments) using a novel methodology: we combinatorially defined 18 768 potential segments of patients by a pair of chronic conditions, a sex and an age group, and then ranked segments by (1) frequency, (2) cost and (3) ratios of observed to expected frequencies of co-occurring chronic conditions. We then compiled pairs of conditions that occur more frequently together than otherwise expected. RESULTS 61.5% of the study population suffers from two or more chronic conditions. The most frequent dyad was hypertension and hyperlipidaemia (19%) and the most frequent triad was diabetes, hypertension and hyperlipidaemia (10%). Women aged 50 to 65 with hypertension and hyperlipidaemia were the leading cost segment in the study population. Costs and prevalence of MCC increase with number of conditions and age. The disease dyads associated with the largest observed/expected ratios were pulmonary disease and myocardial infarction. Inter-borough range MCC prevalence was 16%. CONCLUSIONS In this low-income, urban population, MCC is more prevalent (61%) than nationally (42%), motivating further research and intervention in this population. By identifying potential target populations in an interpretable manner, this segmenting methodology has utility for health services analysts.
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Affiliation(s)
- Usnish B Majumdar
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | | | - Patrick Doupe
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Aaron J Baum
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - David J Heller
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Health System Design and Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Erica L Levine
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | | | | | | | - Sandeep P Kishore
- Arnhold Institute for Global Health, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ouayogodé MH, Mainor AJ, Meara E, Bynum JPW, Colla CH. Association Between Care Management and Outcomes Among Patients With Complex Needs in Medicare Accountable Care Organizations. JAMA Netw Open 2019; 2:e196939. [PMID: 31298714 PMCID: PMC6628588 DOI: 10.1001/jamanetworkopen.2019.6939] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality. OBJECTIVE To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included. EXPOSURES Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities. MAIN OUTCOMES AND MEASURES All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post-acute care spending, health care contact days, and continuity of care (from Medicare claims). RESULTS Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities. CONCLUSIONS AND RELEVANCE The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.
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Affiliation(s)
- Mariétou H. Ouayogodé
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Ellen Meara
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- The National Bureau of Economic Research, Cambridge, Massachusetts
| | - Julie P. W. Bynum
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
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Egan BM, Sutherland SE, Tilkemeier PL, Davis RA, Rutledge V, Sinopoli A. A cluster-based approach for integrating clinical management of Medicare beneficiaries with multiple chronic conditions. PLoS One 2019; 14:e0217696. [PMID: 31216301 PMCID: PMC6584004 DOI: 10.1371/journal.pone.0217696] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 05/16/2019] [Indexed: 01/19/2023] Open
Abstract
Background Approximately 28% of adults have ≥3 chronic conditions (CCs), accounting for two-thirds of U.S. healthcare costs, and often having suboptimal outcomes. Despite Institute of Medicine recommendations in 2001 to integrate guidelines for multiple CCs, progress is minimal. The vast number of unique combinations of CCs may limit progress. Methods and findings To determine whether major CCs segregate differentially in limited groups, electronic health record and Medicare paid claims data were examined in one accountable care organization with 44,645 Medicare beneficiaries continuously enrolled throughout 2015. CCs predicting clinical outcomes were obtained from diagnostic codes. Agglomerative hierarchical clustering defined 13 groups having similar within group patterns of CCs and named for the most common CC. Two groups, congestive heart failure (CHF) and kidney disease (CKD), included 23% of beneficiaries with a very high CC burden (10.5 and 8.1 CCs/beneficiary, respectively). Five groups with 54% of beneficiaries had a high CC burden ranging from 7.1 to 5.9 (descending order: neurological, diabetes, cancer, cardiovascular, chronic pulmonary). Six groups with 23% of beneficiaries had an intermediate-low CC burden ranging from 4.7 to 0.4 (behavioral health, obesity, osteoarthritis, hypertension, hyperlipidemia, ‘other’). Hypertension and hyperlipidemia were common across groups, whereas 80% of CHF segregated to the CHF group, 85% of CKD to CKD and CHF groups, 82% of cancer to Cancer, CHF, and CKD groups, and 85% of neurological disorders to Neuro, CHF, and CKD groups. Behavioral health diagnoses were common only in groups with a high CC burden. The number of CCs/beneficiary explained 36% of the variance (R2 = 0.36) in claims paid/beneficiary. Conclusions Identifying a limited number of groups with high burdens of CCs that disproportionately drive costs may help inform a practical number of integrated guidelines and resources required for comprehensive management. Cluster informed guideline integration may improve care quality and outcomes, while reducing costs.
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Affiliation(s)
- Brent M. Egan
- Care Coordination Institute, Prisma Health, Greenville, South Carolina, United States of America
- School of Medicine-Greenville, University of South Carolina, Greenville, South Carolina, United States of America
- Department of Medicine, Prisma Health Upstate, Greenville, South Carolina, United States of America
- * E-mail:
| | - Susan E. Sutherland
- Care Coordination Institute, Prisma Health, Greenville, South Carolina, United States of America
- School of Medicine-Greenville, University of South Carolina, Greenville, South Carolina, United States of America
| | - Peter L. Tilkemeier
- School of Medicine-Greenville, University of South Carolina, Greenville, South Carolina, United States of America
- Department of Medicine, Prisma Health Upstate, Greenville, South Carolina, United States of America
| | - Robert A. Davis
- Care Coordination Institute, Prisma Health, Greenville, South Carolina, United States of America
- School of Medicine-Greenville, University of South Carolina, Greenville, South Carolina, United States of America
| | - Valinda Rutledge
- Care Coordination Institute, Prisma Health, Greenville, South Carolina, United States of America
| | - Angelo Sinopoli
- Care Coordination Institute, Prisma Health, Greenville, South Carolina, United States of America
- School of Medicine-Greenville, University of South Carolina, Greenville, South Carolina, United States of America
- Department of Medicine, Prisma Health Upstate, Greenville, South Carolina, United States of America
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Bannon BL, Lucier M, Fagerlin A, Kim J, Kiraly B, Weir P, Ozanne EM. Evaluation of the intensive outpatient clinic: study protocol for a prospective study of high-cost, high-need patients in the University of Utah Health system. BMJ Open 2019; 9:e024724. [PMID: 30782742 PMCID: PMC6361483 DOI: 10.1136/bmjopen-2018-024724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The University of Utah (UofU) Health intensive outpatient clinic (IOC) is a primary care clinic for medically complex (high-cost, high-need) patients with Medicaid. The clinic consists of a multidisciplinary care team aimed at providing coordinated, comprehensive and patient-centred care. The protocol outlines the quantitative design of an evaluation study to determine the IOC's effects on reducing healthcare utilisation and costs, as well as improving patient-reported health outcomes and quality of care. METHODS AND ANALYSIS High-risk patients, with high utilisation and multiple chronic illnesses, were identified in the Medicaid ACO population managed by the UofU Health plans for IOC eligibility. A prospective, case-control study design is being used to match 100 IOC patients to 200 control patients (receiving usual care within the UofU) based on demographics, health utilisation and medical complexity for evaluating the primary outcome of change in healthcare utilisation and costs. For the secondary outcomes of patient health and care quality, a prepost design will be used to examine within-person change across the 18 months of follow-up (ie, before and after IOC intervention). Logistic regression and hierarchical, longitudinal growth modelling are the two primary modelling approaches. ETHICS AND DISSEMINATION This work has received ethics approval by the UofU Institutional Review Board. Results from the evaluation of primary and secondary outcomes will be disseminated in scientific research journals and presented at national conferences.
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Affiliation(s)
- Brittany L Bannon
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michelle Lucier
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
- VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, Utah, USA
| | - Jaewhan Kim
- Department of Health and Kinesiology, University of Utah, Salt Lake City, Utah, USA
| | - Bernadette Kiraly
- Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Weir
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Elissa M Ozanne
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Sevak P, Stepanczuk CN, Bradley KWV, Day T, Peterson G, Gilman B, Blue L, Kranker K, Stewart K, Moreno L. Effects of a community-based care management model for super-utilizers. Am J Manag Care 2018; 24:e365-e370. [PMID: 30452205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES Medicare, Medicaid, and commercial plans have all explored ways to improve outcomes for patients with high costs and complex medical and social needs. The purpose of this study was to test the effectiveness of a high-intensity care management program that the Rutgers University Center for State Health Policy (CSHP) implemented as an adaptation of a promising model developed by the Camden Coalition of Healthcare Providers. STUDY DESIGN We estimated the impact of the program on 6 utilization and spending outcomes for a subgroup of beneficiaries enrolled in Medicare fee-for-service (n = 149) and a matched comparison group (n = 1130). METHODS We used Medicare claims for all analyses. We used propensity score matching to construct a comparison group of beneficiaries with baseline characteristics similar to those of program participants. We employed regression models to test the relationship between program enrollment and outcomes over a 12-month period while controlling for baseline characteristics. RESULTS A test of joint significance across all outcomes showed that the CSHP program reduced service use and spending in aggregate (P = .012), although estimates for most of the individual measures were not statistically significant. Participants had 37% fewer unplanned readmissions (P = .086) than did comparison beneficiaries. Although we did not find statistically significant results for the other 5 outcomes, the CIs for these outcomes spanned substantively large effects. CONCLUSIONS Although these findings are mixed, they suggest that adaptations of the Camden model hold promise for reducing short-term service use and spending for Medicare super-utilizers.
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Affiliation(s)
- Purvi Sevak
- Mathematica Policy Research, 600 Alexander Park, Princeton, NJ 08540.
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Wammes JJG, van der Wees PJ, Tanke MAC, Westert GP, Jeurissen PPT. Systematic review of high-cost patients' characteristics and healthcare utilisation. BMJ Open 2018; 8:e023113. [PMID: 30196269 PMCID: PMC6129088 DOI: 10.1136/bmjopen-2018-023113] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 06/05/2018] [Accepted: 07/17/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries. DESIGN Systematic review. DATA SOURCES PubMed and Embase databases were searched until 30 October 2017. ELIGIBILITY CRITERIA AND OUTCOMES Our final search was built on three themes: 'high-cost', 'patients', and 'cost' and 'cost analysis'. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen's behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics. RESULTS The studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients' utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life. CONCLUSIONS High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.
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Affiliation(s)
- Joost Johan Godert Wammes
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Philip J van der Wees
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Marit A C Tanke
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
| | - Gert P Westert
- Radboud University Medical Center, Scientific Center for Quality of Healthcare, Nijmegen, The Netherlands
| | - Patrick P T Jeurissen
- Radboud University Medical Center, Scientific Center for Quality of Healthcare/Celsus Academy for Sustainable Healthcare, Nijmegen, The Netherlands
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Schoen C, Davis K, Willink A, Buttorf C. A Policy Option to Enhance Access and Affordability for Medicare’s Low-Income Beneficiaries. Issue Brief (Commonw Fund) 2018; 2018:1-15. [PMID: 30211508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
ISSUE An estimated 40 percent of low-income Medicare beneficiaries spend 20 percent or more of their incomes on premiums and health care costs. Low-income beneficiaries with multiple chronic conditions or high need are at particular risk of financial hardship. High cost burdens reflect Medicare premiums and cost-sharing, gaps in benefits, and limited assistance. Existing policies to help people with low incomes are fragmented — meaning that beneficiaries apply separately, sometimes to different offices — and require Medicare beneficiaries to navigate complex applications. GOALS With the goal of enhancing access and affordability for people vulnerable due to low incomes and poor health, this issue brief proposes a policy that would reduce Medicare’s cost-sharing and premiums for beneficiaries with incomes below 150 percent of the federal poverty level. METHODS Profile current cost burdens by income groups and assess the potential impact of a policy to expand cost-sharing and premium assistance using the 2012 Medicare Current Beneficiary Survey projected to 2016. RESULTS AND CONCLUSION The policy described could help 8.1 million low-income beneficiaries, significantly lowering their risk of high cost burdens. It also could simplify the administration of assistance provided to these enrollees.
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Affiliation(s)
| | - Karen Davis
- Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Amber Willink
- Department of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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O'Malley AS, Sarwar R, Keith R, Balke P, Ma S, McCall N. Provider Experiences with Chronic Care Management (CCM) Services and Fees: A Qualitative Research Study. J Gen Intern Med 2017; 32:1294-1300. [PMID: 28755097 PMCID: PMC5698215 DOI: 10.1007/s11606-017-4134-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 05/25/2017] [Accepted: 07/06/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Support for ongoing care management and coordination between office visits for patients with multiple chronic conditions has been inadequate. In January 2015, Medicare introduced the Chronic Care Management (CCM) payment policy, which reimburses providers for CCM activities for Medicare beneficiaries occurring outside of office visits. OBJECTIVE To explore the experiences, facilitators, and challenges of practices providing CCM services, and their implications going forward. DESIGN Semi-structured telephone interviews from January to April 2016 with 71 respondents. PARTICIPANTS Sixty billing and non-billing providers and practice staff knowledgeable about their practices' CCM services, and 11 professional society representatives. KEY RESULTS Practice respondents noted that most patients expressed positive views of CCM services. Practice respondents also perceived several patient benefits, including improved adherence to treatment, access to care team members, satisfaction, care continuity, and care coordination. Facilitators of CCM provision included having an in-practice care manager, patient-centered medical home recognition, experience developing care plans, patient trust in their provider, and supplemental insurance to cover CCM copayments. Most billing practices reported few problems obtaining patients' consent for CCM, though providers felt that CMS could better facilitate consent by marketing CCM's goals to beneficiaries. Barriers reported by professional society representatives and by billing and non-billing providers included inadequacy of CCM payments to cover upfront investments for staffing, workflow modification, and time needed to manage complex patients. Other barriers included inadequate infrastructure for health information exchange with other providers and limited electronic health record capabilities for documenting and updating care plans. Practices owned by hospital systems and large medical groups faced greater bureaucracy in implementing CCM than did smaller, independent practices. CONCLUSIONS Improving providers' experiences with and uptake of CCM will require addressing several challenges, including the upfront investment for CCM set-up and the time required to provide CCM to more complex patients.
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Affiliation(s)
- Ann S O'Malley
- Mathematica Policy Research, 1100 First St., NE, 12th Floor, Washington, DC, 20002-4221, USA.
| | - Rumin Sarwar
- Mathematica Policy Research, 1100 First St., NE, 12th Floor, Washington, DC, 20002-4221, USA
| | - Rosalind Keith
- Mathematica Policy Research, 1100 First St., NE, 12th Floor, Washington, DC, 20002-4221, USA
| | - Patrick Balke
- Mathematica Policy Research, 1100 First St., NE, 12th Floor, Washington, DC, 20002-4221, USA
| | - Sai Ma
- The Innovation Center (CMMI), Centers for Medicare & Medicaid Services (CMS), Baltimore, MD, USA
| | - Nancy McCall
- Mathematica Policy Research, 1100 First St., NE, 12th Floor, Washington, DC, 20002-4221, USA
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13
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Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of Children With Multiple Chronic Conditions to Pediatric Hospitalizations in the United States: A Retrospective Cohort Analysis. Hosp Pediatr 2017; 7:365-372. [PMID: 28634168 PMCID: PMC5485355 DOI: 10.1542/hpeds.2016-0179] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Children with multiple chronic conditions (CMCC) are increasingly using hospital care. We assessed how much of US pediatric inpatient care is used by CMCC and which chronic conditions are the key drivers of hospital use. METHODS A retrospective analysis of all 2.3 million US acute-care hospital discharges in 2012 for children age 0 to 18 years in the Kids' Inpatient Database. The ∼4.5 million US hospitalizations for pregnancy, childbirth, and newborn and neonatal care were not assessed. We adapted the Agency for Healthcare Research and Quality's Chronic Condition Indicators to classify hospitalizations for children with no, 1, or multiple chronic conditions, and to determine which specific chronic conditions of CMCC are associated with high hospital resource use. RESULTS Of all pediatric acute-care hospitalizations, 34.3% were of children with no chronic conditions, 36.5% were of those with 1 condition, and 29.3% were of CMCC. Of the $23.6 billion in total hospital costs, 19.7%, 27.4%, and 53.9% were for children with 0, 1, and multiple conditions, respectively, and similar proportions were observed for hospital days. The three populations accounted for the most hospital days were as follows: children with no chronic condition (20.9%), children with a mental health condition and at least 1 additional chronic condition (20.2%), and children with a mental health condition without an additional chronic condition (13.3%). The most common mental health conditions were substance abuse disorders and depression. CONCLUSIONS CMCC accounted for over one-fourth of acute-care hospitalizations and one-half of all hospital dollars for US pediatric care in 2012. Substantial CMCC hospital resource use involves children with mental health-related conditions.
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Affiliation(s)
- Jay G Berry
- Department of Medicine, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Arlene S Ash
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Eyal Cohen
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Fareesa Hasan
- Division of Graduate Medical Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Chris Feudtner
- Division of General Pediatrics, PolicyLab, Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
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Ward BW. Barriers to Health Care for Adults With Multiple Chronic Conditions: United States, 2012-2015. NCHS Data Brief 2017:1-8. [PMID: 28282022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Data from the National Health Interview Survey •In 2015, the percentage of adults aged 18-64 who delayed or did not obtain needed medical care due to cost in the past 12 months was highest among those diagnosed with 2 or more of 10 selected chronic conditions (16.9%), and it was lowest among those with none of the selected conditions (8.5%). •The percentage of adults who delayed needed medical care for a non-cost reason in the past 12 months increased as the number of conditions increased. •The percentage of adults who had seen or talked to a health professional in the past 12 months increased as the number of conditions increased. •For 2012-2015, the percentage of adults aged 18-64 with two or more conditions who delayed or did not obtain needed medical care due to cost decreased, while the percentage who delayed medical care for a non-cost reason increased. In 2014, 25.7% of adults had been diagnosed with multiple chronic conditions (MCC), or 2 or more of 10 selected chronic conditions, including hypertension, cancer, stroke, coronary heart disease, diabetes, arthritis, hepatitis, current asthma, weak or failing kidneys, and chronic obstructive pulmonary disease (1). As the number of chronic conditions increases, so do the health care costs for those diagnosed with MCC (2). In addition, the costs of managing these conditions further increases with advancing age (3). This report examines health care access and utilization among adults with MCC compared with those with one or no diagnosed chronic conditions.
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Markle-Reid M, Ploeg J, Fraser KD, Fisher KA, Akhtar-Danesh N, Bartholomew A, Gafni A, Gruneir A, Hirst SP, Kaasalainen S, Stradiotto CK, Miklavcic J, Rojas-Fernandez C, Sadowski CA, Thabane L, Triscott JAC, Upshur R. The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial. Trials 2017; 18:55. [PMID: 28166816 PMCID: PMC5294729 DOI: 10.1186/s13063-017-1795-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/11/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends). METHODS/DESIGN The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration. DISCUSSION This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap. TRIAL REGISTRATION ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.
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Affiliation(s)
- Maureen Markle-Reid
- Aging, Community and Health Research Unit (ACHRU), School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Jenny Ploeg
- Aging, Community and Health Research Unit (ACHRU), School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Kimberly D. Fraser
- Faculty of Nursing, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Kathryn Ann Fisher
- Aging, Community and Health Research Unit (ACHRU), School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Noori Akhtar-Danesh
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Amy Bartholomew
- Aging, Community and Health Research Unit (ACHRU), School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Amiram Gafni
- Department of Clinical Epidemiology and Biostatistics, Centre for Health Economics and Policy Analysis, McMaster University, 1280 Main Street, Hamilton, ON L8S 4K1 Canada
| | - Andrea Gruneir
- Department of Family Medicine, University of Alberta, 6-40 University Terrace, Edmonton, AB T6G 2T4 Canada
| | - Sandra P. Hirst
- Faculty of Nursing, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 1N4 Canada
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Caralyn Kelly Stradiotto
- Aging, Community and Health Research Unit (ACHRU), School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - John Miklavcic
- Faculty of Nursing, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Carlos Rojas-Fernandez
- Department of Family Medicine, McMaster School of Medicine, Principal, CRF Consulting, 763 Cedar Bend Drive, Waterloo, ON N2V 2R6 Canada
| | - Cheryl A. Sadowski
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, 3-229 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, AB T6G 1C9 Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology and Biostatistics, St. Joseph’s Healthcare Hamilton, Room H-325, 50 Charlton Avenue East, Hamilton, ON L8N 4A6 Canada
| | - Jean A. C. Triscott
- Care of the Elderly Division, Department of Family Medicine, University of Alberta, Edmonton, AB T6G 2R7 Canada
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON M5T 3M7 Canada
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Soto-Gordoa M, Arrospide A, Merino Hernández M, Mora Amengual J, Fullaondo Zabala A, Larrañaga I, de Manuel E, Mar J. Incorporating Budget Impact Analysis in the Implementation of Complex Interventions: A Case of an Integrated Intervention for Multimorbid Patients within the CareWell Study. Value Health 2017; 20:100-106. [PMID: 28212950 DOI: 10.1016/j.jval.2016.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 07/26/2016] [Accepted: 08/09/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To develop a framework for the management of complex health care interventions within the Deming continuous improvement cycle and to test the framework in the case of an integrated intervention for multimorbid patients in the Basque Country within the CareWell project. METHODS Statistical analysis alone, although necessary, may not always represent the practical significance of the intervention. Thus, to ascertain the true economic impact of the intervention, the statistical results can be integrated into the budget impact analysis. The intervention of the case study consisted of a comprehensive approach that integrated new provider roles and new technological infrastructure for multimorbid patients, with the aim of reducing patient decompensations by 10% over 5 years. The study period was 2012 to 2020. RESULTS Given the aging of the general population, the conventional scenario predicts an increase of 21% in the health care budget for care of multimorbid patients during the study period. With a successful intervention, this figure should drop to 18%. The statistical analysis, however, showed no significant differences in costs either in primary care or in hospital care between 2012 and 2014. The real costs in 2014 were by far closer to those in the conventional scenario than to the reductions expected in the objective scenario. The present implementation should be reappraised, because the present expenditure did not move closer to the objective budget. CONCLUSIONS This work demonstrates the capacity of budget impact analysis to enhance the implementation of complex interventions. Its integration in the context of the continuous improvement cycle is transferable to other contexts in which implementation depth and time are important.
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Affiliation(s)
- Myriam Soto-Gordoa
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain; Kronikgune, Barakaldo, Spain.
| | - Arantzazu Arrospide
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain; Health Services Research on Chronic Patients Network (REDISSEC), Kronikgune Group, Barakaldo, Spain; Biodonostia Health Research Institute, San Sebastian-Donostia, Spain
| | - Marisa Merino Hernández
- Biodonostia Health Research Institute, San Sebastian-Donostia, Spain; Tolosaldea Integrated Health Care Organization, Tolosa, Spain
| | | | | | - Igor Larrañaga
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain
| | | | - Javier Mar
- AP-OSI Research Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain; Health Services Research on Chronic Patients Network (REDISSEC), Kronikgune Group, Barakaldo, Spain; Biodonostia Health Research Institute, San Sebastian-Donostia, Spain; Clinical Management Unit, Alto Deba Integrated Health Care Organization, Mondragon, Spain
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Kymes SM, Pierce RL, Girdish C, Matlin OS, Brennan T, Shrank WH. Association among change in medical costs, level of comorbidity, and change in adherence behavior. Am J Manag Care 2016; 22:e295-e301. [PMID: 27556832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Interventions to improve medication adherence are effective, but resource intensive. Interventions must be targeted to those who will potentially benefit most. We examined what heterogeneity exists in the value of adherence based on levels of comorbidity, and the changes in spending on medical services that followed changes in adherence behavior. STUDY DESIGN Retrospective cohort study examining medical spending for 2 years (April 1, 2011, to March 31, 2013) in commercial insurance beneficiaries. METHODS Multivariable linear modeling was used to adjust for differences in patient characteristics. Analyses were performed at the patient/condition level in 2 cohorts: adherent at baseline and nonadherent at baseline. RESULTS We evaluated 857,041 patients, representing 1,264,797 patient therapies consisting of 40% high cholesterol, 48% hypertension, and 12% diabetes. Among those with 3 or more conditions, annual savings associated with becoming adherent were $5341, $4423, and $2081 for patients with at least diabetes, hypertension, and high cholesterol, respectively. The increased costs for patients in this group who became nonadherent were $4653, $7946, and $4008, respectively. Depending on the condition and the direction of behavior change, savings were 2 to 7 times greater than the value for individuals with fewer than 3 conditions. In most cases, the value of preventing nonadherence (ie, persistence) was greater than the value of moving people who are nonadherent to an adherent state. CONCLUSIONS There is important heterogeneity in the impact of medication adherence on medical spending. Clinicians and policy makers should consider this when promoting the change of adherence behavior.
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