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Publications of Note

Weak Association Between Medical Home Features and Outcomes in Safety-Net Settings

Researchers examining whether adoption of patient-centered medical home features is associated with better clinical performance in safety-net settings found that for some domains—care management, test/referral tracking, quality improvement, and external coordination—there was little to no effect on outcome measures related to hypertension control and diabetes control. They found one domain—access/communication—was associated with improved outcomes, while another—patient tracking/registry—was associated with worse outcomes. L. Shi, D. C. Lock, D. Lee et al., “Patient-Centered Medical Home Capability and Clinical Performance in HRSA-Supported Health Centers,” Medical Care, May 2015 53(5):389–95.

Medication Adherence Improves with Social Support

A study designed to investigate the potential benefits of integrating a patient-selected support person into an automated diabetes telemonitoring and self-management program found participants with a support person demonstrated significantly greater improvement in long-term medication adherence than those who participated alone. When investigating whether these benefits varied by patients’ baseline level of psychological distress, the researchers found among those patients, the odds of weekly nonadherence tended to decrease 25 percent per week for those with a support person, yet remained high for those who participated alone. The study included patients with type 2 diabetes who participated in three to six months of weekly automated telemonitoring via interactive voice response calls, with the option of designating a supportive relative or friend to receive automated updates on the patient’s health and self-management, along with guidance regarding potential assistance they could offer. J. E. Aikens, R. Trivedi, D. C. Aron et al., “Integrating Support Persons into Diabetes Telemonitoring to Improve Self-Management and Medication Adherence,” Journal of General Internal Medicine, March 2015 30(3):319–26.

For Medicaid Population, Care Management Reduces Hospital Spending

A care coordination intervention implemented for clinically complex Medicaid beneficiaries in Washington State found it reduced inpatient hospital costs by $318 per member per month among patients who used the program. Known as the Chronic Care Management program, the intervention provided intensive care management, care coordination, and patient education and training in self-management skills for high-risk Medicaid beneficiaries with disabilities. The estimated reduction in overall medical costs of $248 per member per month exceeded the cost of the intervention, but did not reach statistical significance. The program was limited to patients with functional limitations who received in-home personal care to assist them with activities of daily living. J. Xing, C. Goehring, and D. Mancuso, “Care Coordination Program for Washington State Medicaid Enrollees Reduced Inpatient Hospital Costs,” Health Affairs, April 2015 34(4):653–61.

Screening Older Patients for Palliative Care Needs May Reduce ICU Admissions

This article describes the Geriatric Emergency Department Innovations through Workforce, Informatics, and Structural Enhancements, or GEDI WISE, model, which integrates palliative care into emergency department services for older adults. As part of the model, created at Mount Sinai Medical Center, staff screen older adults who may benefit from advance care planning or are suitable for and interested in palliative or hospice care and make referrals as needed. A study of the program found that between January 2011 and May 2013 the percentage of geriatric emergency department admissions to the intensive care unit fell significantly, from 2.3 percent to 0.9 percent, generating an estimated savings of more than $3 million. The authors note the decline in admissions cannot be confidently attributed to the GEDI WISE program because other geriatric care innovations were implemented during the study period. C. Grudzen, L. D. Richardson, and K. M. Baumlin, “Redesigned Geriatric Emergency Care May Have Helped Reduce Admissions of Older Adults to Intensive Care Units,” Health Affairs, May 2015 34(5):788–95.

Performance Incentives at Fairview Health Services Had Greatest Impact on Worst-Performing Physicians

Researchers studying the impact of Fairview Health Services’ compensation model, which tied 40 percent of primary care provider compensation to performance on clinic-level quality outcomes, found that it narrowed the performance gaps between primary care providers, but did not produce greater improvement on quality metrics than that of comparable Minnesota medical groups. The authors say the providers who were most affected by the model were those with comparatively low quality ratings prior to its implementation. Those whose baseline performance was in the lowest tertile improved three times more, on average, across the three quality metrics studied than those in the middle tertile, and almost six times more than those in the top tertile. They also found a narrowing of the gap in quality between providers who treated the highest-income patient panels and those who treated the lowest-income panels. J. Greene, J. H. Hibbard, and V. Overton. “Large Performance Incentives Had the Greatest Impact on Providers Whose Quality Metrics Were Lowest at Baseline,” Health Affairs, April 2015 34(4):673–80.

Hospitals Employing Three or More Strategies to Reduce Readmissions Do Better Than Those with Fewer

A study of hospitals that participated in the Hospital-to-Home and State Action on Avoidable Rehospitalizations initiatives, which were designed to reduce unplanned readmissions, found that hospitals that employed three or more strategies to reduce 30-day readmissions for patients with heart failure achieved the greatest reductions. The diversity of strategies used suggests that many alternative approaches to readmissions reduction may be successful. One, however, stood out: routinely discharging patients with a follow-up appointment already scheduled. E. H. Bradley, H. Sipsma, and L. I. Horwitz, “Hospital Strategy Uptake and Reductions in Unplanned Readmission Rates for Patients with Heart Failure: A Prospective Study,” Journal of General Internal Medicine, May 2015 30(5):605–11.

IOM Recommends New Measures for Collecting Information on Social and Behavioral Factors That Influence Health

The authors of this commentary describe a set of measures that could be embedded into electronic health record systems to collect information about the social and behavioral factors that influence health and mortality. The proposed measures are designed to assess income, education, stress levels, and behaviors such as smoking and exercise, among others, to help health care providers identify risk factors and tailor services to patient needs. The authors are cochairs of the Institute of Medicine’s Committee on Recommended Social and Behavioral Domains and Measures for Electronic Health Records. N. E. Adler and W. W. Stead, “Patients in Context—EHR Capture of Social and Behavioral Determinants of Health,” New England Journal of Medicine, Feb. 2015 372(8):698–701.

A Formula for Assessing Whether Treatment Costs Are Justified by Improved Health Outcomes

To determine whether cost increases related to new treatments are offset by increases in value to patients, researchers looked at how treatment advances in colorectal cancer and multiple myeloma have altered both the cost of treatment and its overall value. To do so, they calculated the quality-adjusted cost of care, which represents the difference between a change in cost and the value of improved health outcomes, as measured by quality-adjusted life years. They found that for colorectal cancer, an increase in the cost of treating the condition—$34,493—was offset by increases in health improvements valued at $33,115 per person. Thus, quality-adjusted cost of care increased only $1,377 between 1998 and 2005. For multiple myeloma, the quality-adjusted cost of care fell by $67,683, with benefits largely concentrated in patients who received innovative therapies used as second-line treatment. For patients receiving only established first-line treatments, the quality-adjusted cost of care for this group rose by $49,000 per patient by 2009. The authors concluded that for patients who responded to established first-line treatment, society got less than it paid for, while for patients responding to new second-line treatment, society got more. D. Lakdawalla, J. Shafrin, C. Lucarelli et al., “Quality-Adjusted Cost of Care: A Meaningful Way to Measure Growth in Innovation Cost Versus the Value of Health Gains,” Health Affairs, April 2015 34(4):555–61.

Nursing Home Ratings Appear to Exacerbate Disparities for Dual Eligibles

To determine whether public reporting of nursing home quality inadvertently exacerbates disparities, researchers compared the extent to which one vulnerable and disadvantaged population—those dually eligible for the Medicare and Medicaid programs—avoided lowest-rated nursing homes compared with other patients once the Centers for Medicare and Medicaid Services’ five-star rating system was implemented in 2008. They found both groups resided in better-quality homes over time, but that by 2010 the increased likelihood of choosing the highest-rated homes was substantially smaller for dual eligibles than for non–dual eligibles. They also note that the benefit to dual eligible patients was largely the result of providers’ improving their ratings, and not of consumers choosing different providers. Increasing Medicaid payments to nursing homes may help to ensure dual eligibles have access to higher-rated facilities, they note. R. T. Konetzka, D. C. Grabowski, M. C. Perraillon et al., “Nursing Home 5-Star Rating System Exacerbates Disparities in Quality, by Payer Source,” Health Affairs, May 2015 43(5):819–27.

Integration of Behavioral and Physical Health Care Services Improves Depression Scores

A collaborative care model that integrated behavioral and physical health services for patients who had depressive symptoms and a history of diabetes, heart disease, or both was found to reduce depression scores. The model, which offered patients in England up to eight sessions of psychological treatment with two treatment sessions delivered jointly with the practice nurse, reduced mean depressive scores by 0.23 points. Patients in the intervention arm also reported being better at managing their conditions, rated their care as more patient-centered, and were more satisfied with their care. There were no significant differences between groups in terms of quality of life, disease-specific quality of life, self-efficacy, disability, and social support. The results suggest that treatment that incorporates brief low-intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self-management of chronic disease in people with mental and physical comorbidities, but the size of the treatment effects were modest. P. Coventry, K. Lovell, C. Dickens et al., “Integrated Primary Care for Patients with Mental and Physical Multimorbidity: Cluster Randomised Controlled Trial of Collaborative Care for Patients with Depression Comorbid with Diabetes or Cardiovascular Disease," BMJ, Feb. 2015 350:h638.

Risk of Readmission and Death Varies by Condition and Declines Slowly for Medicare Beneficiaries

A study of more than 3 million Medicare beneficiaries who survived hospitalization for heart failure, acute myocardial infarction (AMI), or pneumonia found that risk of readmission or death declines slowly for older patients after hospitalization and is at increased levels for months. The specific risk trajectories vary by discharge diagnosis and outcome. Readmission to hospital and death, respectively, occurred following 67.4 percent and 35.8 percent of hospitalizations for heart failure, 49.9 percent and 25.1 percent for AMI, and 55.6 percent and 31.1 percent for pneumonia. Risk of readmission declined by 50 percent after day 38 for heart failure hospitalizations, day 13 after AMI hospitalizations, and day 25 for pneumonia hospitalizations. Risk of death declined by 50 percent after days 11, 6, and 10 for these three conditions, respectively. The authors suggest patients remain vigilant for deterioration in health for an extended time after discharge and that health providers use knowledge of absolute risks and their changes over time to better align interventions designed to reduce adverse outcomes after discharge with the highest-risk periods for patients. K. Dharmarajan, A. F. Hsieh, V. Kulkarni et al., “Trajectories of Risk After Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia: Retrospective Cohort Study,” BMJ, Feb. 2015 350(1):h411.

Primary Care Practice Characteristics Associated with Diabetes Care Improvement

A study investigating three approaches to implementing the Chronic Care Model in primary care practices found that structural and demographic characteristics as well as practice culture significantly affected degree of improvement in diabetes care. The practices studied used one of three methods to implement the model: practice facilitation using a continuous quality improvement (CQI) approach; Reflective Adaptive Process (RAP), an approach for building organizational capacity for change that is less structured; and a self-directed approach. The study found smaller and rural practices using the first two methods displayed greater improvement in diabetes process-of-care measures, while rural and higher-percentage Medicaid practices that were self-directed displayed less improvement. Practices with higher work culture scores had greater improvement overall. But the association between “change culture” scores and process improvement was mixed. CQI practices with higher change culture scores had greater improvement but the opposite relationship was observed in RAP practices, suggesting the relationship between practice culture and practice transformation is complex. L. M. Dickinson, W. P. Dickinson, P. A. Nutting et al., “Practice Context Affects Efforts to Improve Diabetes Care for Primary Care Patients: A Pragmatic Cluster Randomized Trial,” Journal of General Internal Medicine, April 2015 30(4):476–82.

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