The Transforming Outcomes for Patients Through Medical Home Evaluation and reDesign (TOPMED) Cluster Randomized Controlled Trial: Cost and Utilization Results

BACKGROUND

Primary Care Medical Home (PCMH) redesign efforts are intended to enhance primary care's ability to improve population health and well-being. PCMH transformation that is focused on "high-value elements" (HVEs) for cost and utilization may improve effectiveness.

OBJECTIVES

The objective of this study was to determine if a focus on achieving HVEs extracted from successful primary care transformation models would reduce cost and utilization as compared with a focus on achieving PCMH quality improvement goals.

RESEARCH DESIGN

A stratified, cluster randomized controlled trial with 2 arms. All practices received equal financial incentives, health information technology support, and in-person practice facilitation. Analyses consisted of multivariable modeling, adjusting for the cluster, with difference-in-difference results.

SUBJECTS

Eight primary care clinics that were engaged in PCMH reform.

MEASURES

We examined: (1) total claims payments; (2) emergency department (ED) visits; and (3) hospitalizations among patients during baseline and intervention years.

RESULTS

In total, 16,099 patients met the inclusion criteria. Intervention clinics had significantly lower baseline ED visits (P=0.02) and claims paid (P=0.01). Difference-in-difference showed a decrease in ED visits greater in control than intervention (ED per 1000 patients: +56; 95% confidence interval: +96, +15) with a trend towards decreased hospitalizations in intervention (-15; 95% confidence interval: -52, +21). Costs were not different. In modeling monthly outcome means, the generalized linear mixed model showed significant differences for hospitalizations during the intervention year (P=0.03).

DISCUSSION

The trial had a trend of decreasing hospitalizations, increased ED visits, and no change in costs in the HVE versus quality improvement arms.

Assessing Data Adequacy for High Blood Pressure Clinical Decision Support: A Quantitative Analysis

OBJECTIVE

This study examines guideline-based high blood pressure (HBP) and hypertension recommendations and evaluates the suitability and adequacy of the data and logic required for a Fast Healthcare Interoperable Resources (FHIR)-based, patient-facing clinical decision support (CDS) HBP application. HBP is a major predictor of adverse health events, including stroke, myocardial infarction, and kidney disease. Multiple guidelines recommend interventions to lower blood pressure, but implementation requires patient-centered approaches, including patient-facing CDS tools.

METHODS

We defined concept sets needed to measure adherence to 71 recommendations drawn from eight HBP guidelines. We measured data quality for these concepts for two cohorts (HBP screening and HBP diagnosed) from electronic health record (EHR) data, including four use cases (screening, nonpharmacologic interventions, pharmacologic interventions, and adverse events) for CDS.

RESULTS

We identified 102,443 people with diagnosed and 58,990 with undiagnosed HBP. We found that 21/35 (60%) of required concept sets were unused or inaccurate, with only 259 (25.3%) of 1,101 codes used. Use cases showed high inclusion (0.9-11.2%), low exclusion (0-0.1%), and missing patient-specific context (up to 65.6%), leading to data in 2/4 use cases being insufficient for accurate alerting.

DISCUSSION

Data quality from the EHR required to implement recommendations for HBP is highly inconsistent, reflecting a fragmented health care system and incomplete implementation of standard terminologies and workflows. Although imperfect, data were deemed adequate for two test use cases.

CONCLUSION

Current data quality allows for further development of patient-facing FHIR HBP tools, but extensive validation and testing is required to assure precision and avoid unintended consequences.

Identifying Patients with Significant Problems Related to Social Determinants of Health with Natural Language Processing

Social and behavioral factors influence health but are infrequently recorded in electronic health records (EHRs). Here, we demonstrate that psychosocial vital signs can be extracted from EHR data. We processed structured and unstructured EHR data using expert-driven queries and Natural Language Processing (NLP), validating results through structured annotation. We found that although these vital signs are present in EHRs, with 681 structured entries identified for psychosocial concepts, NLP identified a nearly 90-fold increase in patients.

[Effects of intravenous administration of clarithromycin on plasma levels of gastrin and group I pepsinogen]

Erythromycin and some of its derivatives have prokinetic gastrointestinal properties. In addition, erythromycin has been shown to stimulate isolated chief cells of the gastric mucosa, and to activate pepsin secretion. The above study was aimed at ascertaining in a group of dyspeptic patients whether clarithromycin, a structural analogue of erythromycin, is apt to modify certain functional parameters of gastric secretion, above all the patterns of gastrin and PG-I secretion. A 20-minute intravenous clarithromycin infusion (1.5 mg/kg) in fasting subjects has brought about a significant reduction (at 20 and 45 minutes from the start of infusion) of circulating gastrin (about 23%) and, after a meal, a 69% increase. No change of plasma PG-I level was observed either after placebo or after the active substance. These findings suggest that in vivo and at the doses used in our experiment clarithromycin has no influence on plasma PG-I release and is apt to modify the fasting and postprandial gastrin releasing pattern.

[The esophageal motor pattern and the acid exposure of the distal esophagus in patients with gastroesophageal reflux]

Low-compliance standard manometry and 24-hour ambulatory pH monitoring were performed in 42 patients with typical gastro-esophageal reflux (GER) symptoms in order to assess correlations between esophageal motility pattern and pH profile. Our results show: 1) 36% of GER patients had a normal esophageal acid exposure; 2) pH profile and manometric pattern did not differ in patients with mild esophagitis from those without esophagitis; 3) low esophageal sphincter pressure in GER patients was significantly lower than in control subjects, irrespective of acid exposure; 4) the main motility disorders in the distal esophagus of reflux patients was the increased simultaneous wave rate which seemed to affect both recumbent esophageal clearance and reflux time.

[Psycho-emotional distress and gastroesophageal reflux syndrome]

61 patients with symptoms suggestive for gastro-esophageal reflux (GER) disease, with or without endoscopic evidence of esophagitis, were studied in order to recognize any neurotic traits connected to GERD and its esophageal motility disorders. The results were compared with those from a group of patients without digestive diseases as well as those from a control group of the same age and status. Psychological assessment was made by using the Middlesex Hospital Questionnaire and esophageal motility pattern was analyzed with a low-compliance manometric system. Patients with gastro-esophageal reflux (GER), irrespectively or not from esophagitis, showed, after such a psychological assessment, neurotic traits more pronounced than control subjects and patients without digestive disease. In GER patients, it was observed a close relationship between some psychological traits and a few esophageal manometric variable. In the two groups of GER patients, with and without esophagitis, it was not found any significant difference in scores referring to the evaluated psychological traits apart from symptoms somatization, prevailing in GER patients without esophagitis. These results support the pathogenetic role of psychological distresses in the genesis of GER, even if other factors may be necessary to the development of organic inflammatory lesions such as esophagitis.