Importance of Carefully Defining Overuse Measures
The authors of this commentary suggest that developers of overuse measures—those designed to detect usage of tests and treatments that are unnecessary or for which potential harms exceed likely benefits—engage patients, physicians, and other stakeholders to help identify and address potential unintended consequences from their use. To avoid patient harm, developers of measures should also ensure that the data used to identify exclusions are readily available, valid across multiple settings, and accurate indicators of clinical characteristics that indicate a service is beneficial, the authors note. J. S. Mathias and D. W. Baker, "Developing Quality Measures to Address Overuse, Journal of the American Medical Association, May 2013 309(18):1897–8.
Strong Primary Care Systems Associated with Better Outcomes and Higher Costs
Using data collected between 2009 and 2010 from 31 European countries, researchers found that total health care expenditures were higher in countries with stronger primary care infrastructures, although countries with comprehensive primary care service delivery had slower growth in total health care expenditures per capita. They speculate that while maintaining a strong primary care system drives costs higher in the short term, treating a broader range of health problems through primary care reduces overall growth in costs. The researchers also found that stronger primary care systems were associated with lower rates of potentially avoidable hospitalizations and fewer deaths from ischemic heart disease, cerebrovascular disease, chronic asthma, bronchitis, and emphysema. D. S. Kringos, W. Boerma, J. van der Zee et al., "Europe's Strong Primary Care Systems Are Linked to Better Population Health But Also to Higher Health Spending," Health Affairs, April 2013 32(4):686–94.
In First Two Years, Medicaid Coverage Has Modest Impact on Health Outcomes
A study designed to evaluate the impact of Medicaid coverage on clinical care and outcomes found the program lowered rates of depression and nearly eliminated catastrophic out-of-pocket expenses but had no statistically significant effect on the prevalence, diagnosis, or medication of hypertension or high cholesterol. The study, which compared Oregon residents who obtained Medicaid coverage through a 2008 lottery with those who remained uninsured, also found the program increased use of physician services, prescription drugs, and hospitalizations, as well as the likelihood of having a usual source of care. K. Baicker, S. L. Taubman, H. L. Allen, et al., "The Oregon Experiment—Effects of Medicaid on Clinical Outcomes," New England Journal of Medicine, May 2013 368(18):1713–22.
Medication Errors Common Among Children Receiving Cancer Care at Home
A study involving three pediatric oncology clinics found patients undergoing cancer treatment in home settings found medication errors were common, occurring in one-third of observed medication administrations. Four of these errors led to significant patient injury. An additional 40 observed errors had potential for injury: of these, two were life-threatening, 13 were serious, and 25 were significant. The authors note that rates of preventable medication-related injuries in this outpatient population were comparable or higher than those found in studies of hospitalized patients. K. E. Walsh, D. W. Roblin, S. N. Weingart et al., "Medication Errors in the Home: A Multisite Study of Children with Cancer," Pediatrics, May 2013 131(5):e1405–14.
Gaps in Diabetes Care Remain
A study of adults with diabetes in the U.S. found that between 33.4 percent and 48.7 percent of patients did not meet individualized targets for glycemic control, blood pressure, or lipid control, and more than 20 percent remained smokers, although smoking is a risk factor for death. The study also found that 40 percent to 50 percent of adults with diabetes did not receive diabetes education, vaccinations, or annual dental exams. M. K. Ali, K. McKeever Bullard, J. B. Saaddine et al., "Achievement of Goals in U.S. Diabetes Care, 1999–2010," New England Journal of Medicine, April 2013 368(17):1613–24.
Increased Attention to At-Risk Elders Produces Higher Satisfaction But Not Improved Health
A program designed to improve care for older patients at risk for generating high health care expenditures increased patients' ratings of the quality of their care and reduced use of home care, but did not improve the patients' functional health. The program, known as Guided Care, aimed to improve care coordination and comprehensiveness with the help of registered nurses, who collaborated with primary care physicians in providing comprehensive assessments, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services. C. Boult, B. Leff, C. M. Boyd et al., "A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients, Journal of General Internal Medicine, May 2013 28(5):612–21.
Medical Home Demonstration Produces Tepid Results
A patient-centered medical home (PCMH) demonstration involving eight New Jersey primary care practices found health care utilization and costs did not significantly change with the adoption of the model. There was, however, modest improvement on some Healthcare Effectiveness and Data Information Set (HEDIS) quality measures, with rates of mammography increasing in PCMH practices by 2.2 percentage points and rates of nephropathy screening increasing by 6.6 percentage points. Changes in seven other HEDIS quality measures following PCMH implementation were not statistically significant. The authors suggest that ongoing work will be needed to understand why the PCMH model works in some cases and not in others. R. Werner, M. Duggan, K. Duey et al., "The Patient-Centered Medical Home: An Evaluation of a Single Private Payer Demonstration in New Jersey," Medical Care, June 2013 51(6):487–93.
Post–Acute Care a Big Factor in Geographic Variations in Spending
In a commentary, the chairs of an Institute of Medicine committee convened to examine geographic variation in Medicare expenditures note that a substantial part of variation across hospital referral regions stems from spending on post–acute care, including home health services, skilled nursing facilities, and long-term care hospitals—with some of it attributable to fraud. They also found some variation is linked to acute-care services, including physician payments. While the committee has yet to make recommendations on whether Medicare should modify payments to reflect the value of services delivered in a region, the authors note doing so may be a challenge given the variations in performance within individual regions. J. P. Newhouse and A. M. Garber, "Geographic Variation in Medicare Services," New England Journal of Medicine, April 2013 368(16):1465–8.
Achieving Better Outcomes Using Behavioral Economics
The authors of this commentary suggest that providers, patients, policymakers, and industry executives consider using approaches based on behavioral economics to improve health outcomes and control health care spending. They point out several strategies for changing behavior, many of which are designed to prevent mental shortcuts that can lead to unnecessary tests and treatments and decisions that are not aligned with the best interests of patients. Among other things, these strategies include using incentives, careful framing of information, and the general tendency of people to fall back on defaults to achieved desired goals. D. King, F. Greaves, I. Vlaev et al., "Approaches Based on Behavioral Economics Could Nudge Patients and Providers Toward Lower Health Care Spending Growth," Health Affairs, April 2013 32(4):661–8.
An Alternative to Clinical Practice Guidelines Proposed
The authors of this article describe a new method of reducing practice variability that promotes care standardization while still accommodating patients' differences, respecting clinicians' acumen, and incorporating rapidly developing medical knowledge. Standardized clinical assessment and management plans (SCAMPs), as they are known, provide clinicians with multiple care pathways for diverse populations of patients with a given diagnosis or condition. They are based on a literature review and in some instances an analysis of the results of current practices. A SCAMP is accompanied by selective data collection to monitor outcomes and record explanations supplied by providers as to why they deviated from the recommendations. This information enables SCAMP developers to continually and iteratively refine care pathways. Used since 2009, SCAMPs have been credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. They have also been associated with an 11 to 51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. M. Farias, K. Jenkins, J. Lock et al., "Standardized Clinical Assessment and Management Plans (SCAMPs) Provide a Better Alternative to Clinical Practice Guidelines," Health Affairs, May 2013 32(5):911–20.
Approaches for Pursuing Quality and Efficiency: Integration vs. Specialization
The author describes competing approaches to improving the quality and efficiency of services at two high-volume orthopedic hospitals in Irvine, Calif. The first, at Kaiser Permanente Irvine Medical Group, seeks to reduce organizational fragmentation and increase the level of clinical coordination by integrating group practices and hospital systems, thus enabling Kaiser to deliver coordinated care from before admission through discharge and beyond. The second, at Hoag Orthopedic Institute, seeks to improve clinical focus and efficiency by forming a single-specialty facility jointly owned by the physicians and the hospital. The author notes that across markets the integrated approach prevails, even though the pursuit of service-line strategies can create valuable incentives for increasing efficiency and quality. J. C. Robinson, "Case Studies of Orthopedic Surgery in California: The Virtues of Care Coordination Versus Specialization," Health Affairs, May 2013 32(5):921–8.
More Thorough Research on Transformational Change Needed
The authors conducted a systematic review of empirical research on transformational organizational change in health care and other industries in an effort to assess findings, identify areas for future research, and provide guidance to health care organizations. Among many conclusions: there's been a lack of sufficient examination of unsuccessful initiatives, raising concern about the validity of inferences about transformational change; most studies have used short time frames and defined the study period as that for which data were available; and further examination of capacity for transformation is warranted. S. D. Lee, B. J. Weiner, M. I. Harrison et al., "Organizational Transformation: A Systematic Review of Empirical Research in Health Care and Other Industries," Medical Care Research and Review, April 2013 70(2):115–42.
The authors of this commentary suggest that developers of overuse measures—those designed to detect usage of tests and treatments that are unnecessary or for which potential harms exceed likely benefits—engage patients, physicians, and other stakeholders to help identify and address potential unintended consequences from their use. To avoid patient harm, developers of measures should also ensure that the data used to identify exclusions are readily available, valid across multiple settings, and accurate indicators of clinical characteristics that indicate a service is beneficial, the authors note. J. S. Mathias and D. W. Baker, "Developing Quality Measures to Address Overuse, Journal of the American Medical Association, May 2013 309(18):1897–8.
Strong Primary Care Systems Associated with Better Outcomes and Higher Costs
Using data collected between 2009 and 2010 from 31 European countries, researchers found that total health care expenditures were higher in countries with stronger primary care infrastructures, although countries with comprehensive primary care service delivery had slower growth in total health care expenditures per capita. They speculate that while maintaining a strong primary care system drives costs higher in the short term, treating a broader range of health problems through primary care reduces overall growth in costs. The researchers also found that stronger primary care systems were associated with lower rates of potentially avoidable hospitalizations and fewer deaths from ischemic heart disease, cerebrovascular disease, chronic asthma, bronchitis, and emphysema. D. S. Kringos, W. Boerma, J. van der Zee et al., "Europe's Strong Primary Care Systems Are Linked to Better Population Health But Also to Higher Health Spending," Health Affairs, April 2013 32(4):686–94.
In First Two Years, Medicaid Coverage Has Modest Impact on Health Outcomes
A study designed to evaluate the impact of Medicaid coverage on clinical care and outcomes found the program lowered rates of depression and nearly eliminated catastrophic out-of-pocket expenses but had no statistically significant effect on the prevalence, diagnosis, or medication of hypertension or high cholesterol. The study, which compared Oregon residents who obtained Medicaid coverage through a 2008 lottery with those who remained uninsured, also found the program increased use of physician services, prescription drugs, and hospitalizations, as well as the likelihood of having a usual source of care. K. Baicker, S. L. Taubman, H. L. Allen, et al., "The Oregon Experiment—Effects of Medicaid on Clinical Outcomes," New England Journal of Medicine, May 2013 368(18):1713–22.
Medication Errors Common Among Children Receiving Cancer Care at Home
A study involving three pediatric oncology clinics found patients undergoing cancer treatment in home settings found medication errors were common, occurring in one-third of observed medication administrations. Four of these errors led to significant patient injury. An additional 40 observed errors had potential for injury: of these, two were life-threatening, 13 were serious, and 25 were significant. The authors note that rates of preventable medication-related injuries in this outpatient population were comparable or higher than those found in studies of hospitalized patients. K. E. Walsh, D. W. Roblin, S. N. Weingart et al., "Medication Errors in the Home: A Multisite Study of Children with Cancer," Pediatrics, May 2013 131(5):e1405–14.
Gaps in Diabetes Care Remain
A study of adults with diabetes in the U.S. found that between 33.4 percent and 48.7 percent of patients did not meet individualized targets for glycemic control, blood pressure, or lipid control, and more than 20 percent remained smokers, although smoking is a risk factor for death. The study also found that 40 percent to 50 percent of adults with diabetes did not receive diabetes education, vaccinations, or annual dental exams. M. K. Ali, K. McKeever Bullard, J. B. Saaddine et al., "Achievement of Goals in U.S. Diabetes Care, 1999–2010," New England Journal of Medicine, April 2013 368(17):1613–24.
Increased Attention to At-Risk Elders Produces Higher Satisfaction But Not Improved Health
A program designed to improve care for older patients at risk for generating high health care expenditures increased patients' ratings of the quality of their care and reduced use of home care, but did not improve the patients' functional health. The program, known as Guided Care, aimed to improve care coordination and comprehensiveness with the help of registered nurses, who collaborated with primary care physicians in providing comprehensive assessments, evidence-based care planning, proactive monitoring, care coordination, transitional care, coaching for self-management, caregiver support, and access to community-based services. C. Boult, B. Leff, C. M. Boyd et al., "A Matched-Pair Cluster-Randomized Trial of Guided Care for High-Risk Older Patients, Journal of General Internal Medicine, May 2013 28(5):612–21.
Medical Home Demonstration Produces Tepid Results
A patient-centered medical home (PCMH) demonstration involving eight New Jersey primary care practices found health care utilization and costs did not significantly change with the adoption of the model. There was, however, modest improvement on some Healthcare Effectiveness and Data Information Set (HEDIS) quality measures, with rates of mammography increasing in PCMH practices by 2.2 percentage points and rates of nephropathy screening increasing by 6.6 percentage points. Changes in seven other HEDIS quality measures following PCMH implementation were not statistically significant. The authors suggest that ongoing work will be needed to understand why the PCMH model works in some cases and not in others. R. Werner, M. Duggan, K. Duey et al., "The Patient-Centered Medical Home: An Evaluation of a Single Private Payer Demonstration in New Jersey," Medical Care, June 2013 51(6):487–93.
Post–Acute Care a Big Factor in Geographic Variations in Spending
In a commentary, the chairs of an Institute of Medicine committee convened to examine geographic variation in Medicare expenditures note that a substantial part of variation across hospital referral regions stems from spending on post–acute care, including home health services, skilled nursing facilities, and long-term care hospitals—with some of it attributable to fraud. They also found some variation is linked to acute-care services, including physician payments. While the committee has yet to make recommendations on whether Medicare should modify payments to reflect the value of services delivered in a region, the authors note doing so may be a challenge given the variations in performance within individual regions. J. P. Newhouse and A. M. Garber, "Geographic Variation in Medicare Services," New England Journal of Medicine, April 2013 368(16):1465–8.
Achieving Better Outcomes Using Behavioral Economics
The authors of this commentary suggest that providers, patients, policymakers, and industry executives consider using approaches based on behavioral economics to improve health outcomes and control health care spending. They point out several strategies for changing behavior, many of which are designed to prevent mental shortcuts that can lead to unnecessary tests and treatments and decisions that are not aligned with the best interests of patients. Among other things, these strategies include using incentives, careful framing of information, and the general tendency of people to fall back on defaults to achieved desired goals. D. King, F. Greaves, I. Vlaev et al., "Approaches Based on Behavioral Economics Could Nudge Patients and Providers Toward Lower Health Care Spending Growth," Health Affairs, April 2013 32(4):661–8.
An Alternative to Clinical Practice Guidelines Proposed
The authors of this article describe a new method of reducing practice variability that promotes care standardization while still accommodating patients' differences, respecting clinicians' acumen, and incorporating rapidly developing medical knowledge. Standardized clinical assessment and management plans (SCAMPs), as they are known, provide clinicians with multiple care pathways for diverse populations of patients with a given diagnosis or condition. They are based on a literature review and in some instances an analysis of the results of current practices. A SCAMP is accompanied by selective data collection to monitor outcomes and record explanations supplied by providers as to why they deviated from the recommendations. This information enables SCAMP developers to continually and iteratively refine care pathways. Used since 2009, SCAMPs have been credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. They have also been associated with an 11 to 51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. M. Farias, K. Jenkins, J. Lock et al., "Standardized Clinical Assessment and Management Plans (SCAMPs) Provide a Better Alternative to Clinical Practice Guidelines," Health Affairs, May 2013 32(5):911–20.
Approaches for Pursuing Quality and Efficiency: Integration vs. Specialization
The author describes competing approaches to improving the quality and efficiency of services at two high-volume orthopedic hospitals in Irvine, Calif. The first, at Kaiser Permanente Irvine Medical Group, seeks to reduce organizational fragmentation and increase the level of clinical coordination by integrating group practices and hospital systems, thus enabling Kaiser to deliver coordinated care from before admission through discharge and beyond. The second, at Hoag Orthopedic Institute, seeks to improve clinical focus and efficiency by forming a single-specialty facility jointly owned by the physicians and the hospital. The author notes that across markets the integrated approach prevails, even though the pursuit of service-line strategies can create valuable incentives for increasing efficiency and quality. J. C. Robinson, "Case Studies of Orthopedic Surgery in California: The Virtues of Care Coordination Versus Specialization," Health Affairs, May 2013 32(5):921–8.
More Thorough Research on Transformational Change Needed
The authors conducted a systematic review of empirical research on transformational organizational change in health care and other industries in an effort to assess findings, identify areas for future research, and provide guidance to health care organizations. Among many conclusions: there's been a lack of sufficient examination of unsuccessful initiatives, raising concern about the validity of inferences about transformational change; most studies have used short time frames and defined the study period as that for which data were available; and further examination of capacity for transformation is warranted. S. D. Lee, B. J. Weiner, M. I. Harrison et al., "Organizational Transformation: A Systematic Review of Empirical Research in Health Care and Other Industries," Medical Care Research and Review, April 2013 70(2):115–42.
