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Newsletter Article


Publications of Note

High-Quality Preventive and Primary Care Does Not Reduce Spending for Diabetics

A study that examined the relationship between medical care spending and diabetes-related quality measures, including provider-initiated processes of care and patient-dependent activities, did not find support for the assumption that high-quality preventive and primary care combined with effective patient self-management leads to lower costs in the near term. The authors also found no relationship between adjusted spending and intermediate clinical outcomes (e.g., HbA1c levels) measured at the clinic level. They note that additional research is needed to understand whether this assumption may be valid when using outcomes vs. process-based quality measures; alternative disease contexts or populations; or a longer time horizon. J. M. Abraham, D. J. Crespin, J. S. McCullough et al., “What Is the Cost of Quality for Diabetes Care?Medical Care Research and Review, Dec. 2014 71(6):580–98.

Resident Handoff Improvement Program Reduces Medical Errors

A study of a program intended to improve handoffs between medical residents in nine hospitals—measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow—found the program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. The intervention included a mnemonic to standardize oral and written handoffs; handoff and communication training; a faculty development and observation program; and a sustainability campaign. In 10,740 patient admissions, the medical error rate decreased by 23 percent from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions), and the rate of preventable adverse events decreased by 30 percent (4.7 vs. 3.3 events per 100 admissions). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions). A. J. Starmer, N. D. Spector, R. Srivastava et al., “Changes in Medical Errors After Implementation of a Handoff Program,” New England Journal of Medicine, Nov. 2014 371(19):1803–12.

Few ACOs Focus on Integrating Primary Care and Behavioral Health

A study that sought to examine the extent to which accountable care organizations (ACOs) are clinically, organizationally, and financially integrating behavioral health care and primary care found that most ACOs hold responsibility for some behavioral health care costs, and 42 percent include behavioral health specialists among their providers. However, integration of behavioral health care and primary care remains low, with most ACOs pursuing traditional fragmented approaches to physical and behavioral health care and only a minority implementing innovative models. V. A. Lewis, C. H. Colla, K. Tierney et al., “Few ACOs Pursue Innovative Models That Integrate Care for Mental Illness and Substance Abuse with Primary Care,” Health Affairs, Oct. 2014 33(10):1808–16.

Safety-Net ACO Achieves Savings by Addressing the Socioeconomic Determinants of Health

This article describes the efforts of Hennepin Health—a county-based safety-net ACO in Minnesota—to forge community-level partnerships that address the behavioral, social, and economic determinants of health for an expanded community of Medicaid beneficiaries. As a result of the ACO’s efforts, emergency department visits decreased 9.1 percent between 2012 and 2013, while outpatient visits increased 3.3 percent. The article notes an increasing percentage of patients have received diabetes, vascular, and asthma care at optimal levels. At the same time, Hennepin Health has realized savings and reinvested them in future improvements. S. F. Sandberg, C. Erikson, R. Owen et al., “Hennepin Health: A Safety-Net Accountable Care Organization for the Expanded Medicaid Population,” Health Affairs, Nov. 2014 33(11):1975–84.

Taxonomy of ACOs Proposed

In developing a taxonomy of ACOs based on eight attributes, including size, scope of services offered, and the use of performance accountability mechanisms, the authors of this article found the ACOs studied fell into three clusters: 1) larger, integrated systems that offer a broad scope of services and frequently include one or more postacute facilities; 2) smaller, physician-led practices, centered in primary care that possess a relatively high degree of physician performance management; and 3) moderately sized, joint hospital–physician and coalition-led groups that offer a moderately broad scope of services with some involvement of postacute facilities. The authors suggest the taxonomy may provide a useful framework for assessing performance, targeting technical assistance, and for diagnosing potential antitrust violations. S. M. Shortell, F. M. Wu, V. A. Lewis et al., “A Taxonomy of Accountable Care Organizations for Policy and Practice,” Health Services Research, Dec. 2014 49(6):1883–99.

More Flexible Decision Aids Needed for Advance Care Planning

An overview of research related to decision aids and their current use for adult advance care planning found that many decision aids are widely available but are not assessed in the empirical literature. The article notes most decision aids tested as interventions for adult advance care planning were proprietary or not publicly available. Some were constructed for the general population, whereas others addressed disease-specific conditions that have more predictable end-of-life scenarios and, thus, involve more discrete choices. The authors suggest new decision aids be designed that are responsive to diverse philosophical perspectives and flexible enough to change as patients gain experience with their personal illness courses. M. Butler, E. Ratner, E. McCreedy et al., “Decision Aids for Advance Care Planning: An Overview of the State of the Science,” Annals of Internal Medicine, Sept. 2014 161(6):408–14.

Using Social Impact Bonds to Address Social Determinants of Health

This article describes the potential of social impact bonds to address the behavioral, social, and environmental conditions that contribute most to long-term health. Described as a “pay-for-success” model, such bonds rely on investors funding a nonmedical intervention up front while bearing the risk that the intervention may fail to prevent disease in the future. Should the intervention succeed, the investor is repaid in full by a predetermined payer, such as a public health agency, and receives an additional return on its investment as a reward for taking on the risk. Pay-for-success pilots are being developed to reduce asthma-related emergencies among children, poor birth outcomes, and the progression of pre-diabetes to diabetes, among other applications. I. Galloway, “Using Pay-For-Success to Increase Investment in the Nonmedical Determinants of Health,” Health Affairs, Nov. 2014 33(11):1897–1904.

Commentary: Social Impact Bond Programs May Help Promote Evidence-Based Interventions for Children and Youth

This article describes the role social impact bonds can play in encouraging the development and use of cost-beneficial, evidence-based programs in pediatric health, behavioral health, youth juvenile justice, and child welfare. Such programs, which allow private or philanthropic investors to provide up-front funding to a social service provider to use address a social problem, shift the financial risk of supporting such programs from government to investors. E. Trupin, N. Weiss, and S. E. U. Kerns, “Social Impact Bonds: Behavioral Health Opportunities,” JAMA Pediatrics, Nov. 2014 168(11):985–6.

Nurse-Led Discharge Support Fails to Reduce Readmissions for Older, Ethnically Diverse Patient Groups

A study of a nurse-led discharge support program to reduce readmissions and emergency department (ED) use following discharge for a population of ethnically and linguistically diverse older patients admitted to a safety-net hospital found the number of ED visits or readmissions did not differ between the intervention and usual care groups. The patients in the intervention group received in-hospital, one-on-one, self-management education given by a dedicated, language-concordant, registered nurse, combined with telephone follow-up after discharge from a nurse practitioner. The authors recommend testing other readmission prevention strategies with this population. L. E. Goldman, U. Sarkar, E. Kessell et al., “Support from Hospital to Home for Elders: A Randomized Trial,” Annals of Internal Medicine, Oct. 2014 161(7):472–81.

Commentary: Improvement Needed in Quality Measures

This commentary recommends the development of new measures of clinical quality to adequately capture trends in the overall health of individuals and of populations. The author notes there is no definition of “health” in the 2013 National Quality Strategy (NQS)—a report designed to build a national consensus on how to measure quality. He also notes that quality measures endorsed by the National Quality Forum—which are frequently adopted by payers, consumer groups, employers, and others and have been used to detect variation among providers—are built on the assumption that improvements in care will lead to greater health. The author notes that while this may be true for individuals, it has not been demonstrated at a population level where other factors (including genetics, safety, and sociodeterminants of health, among others) are at play. He recommends that measures of “system-ness” and well-being of both individuals and populations be developed. T. James, “Is It Time to Change Directions of Quality Measures?American Journal of Medical Quality, Nov./Dec. 2014 29(6):555–6.

Commentary: Models for Governing and Financing “Accountable Care Communities”

The authors of this commentary recommend that physicians join other stakeholders in community and regional initiatives that are aimed at investing health resources more wisely. They offer several suggestions for structuring effective governance of such “accountable care communities,” as well as methods of funding them, including the use of community benefit funds, shared savings, social investing, and community development financing, among other sources. E. S. Fisher and J. Corrigan, “Accountable Health Communities: Getting There from Here,” Journal of the American Medical Association, Nov. 26, 2014 312(20):2093–4.

Reshaping U.S. Health Care Through Cooperation and Political Mobilization

This editorial argues that reshaping the U.S. health care system to better meet community needs at an affordable cost will require local and regional rather than national action, and the political mobilization of workers and business leaders who have been hard hit by rising health care spending. Establishing shared goals for health care leaders and new business models also may help, but may be difficult to achieve because of the institutional self-interest of health care organizations, the author notes. D. M. Berwick, “Reshaping U.S. Health Care: From Competition and Confiscation to Cooperation and Mobilization,” Journal of the American Medical Association, Nov. 26, 2014 312(20):2099–2100.

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