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Publications of Note

Wide Variation in Cesarean Delivery Rates Found

A study of cesarean delivery rates in U.S. hospitals found the rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteenfold, from 2.4 percent to 36.5 percent. The authors attribute the variation to differences in practice patterns and recommend that four strategies for decreasing variation that is unwarranted. These include better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting. K. B. Kozhimaniil, M. R. Law, and B. A. Virnig, "Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality and Cost Issues," Health Affairs, March 2013 32(3):527–35.

New Model of Primary Care Proposed

The authors of this commentary suggest redesigning the model of primary care so it that is organized around the needs of patients. Their suggestions include organizing practices around subgroups of patients with similar needs; developing teams that are focused on care integration and improvement for each subgroup; measuring individual outcomes and costs by subgroup; and modifying payment to bundle reimbursement for each subgroup and reward value improvement. Finally each subgroup should be integrated with relevant specialty providers. M. Porter, E. A. Pabo, and T. H. Lee, "Redesigning Primary Care: A Strategic Vision to Improve Value by Organizing Around Patients' Needs," Health Affairs, March 2013 32(3):516–25.

Public Reporting Improves Diabetes Care

A survey of more than 400 primary care clinics that have been publicly reporting data on how well they deliver diabetes care found that such public reporting helped drive early adoption of diabetes care improvement activities, including patient registries and care reminders. Public reporting also seems to have promoted the adoption of multiple improvement interventions over time.  G. C. Lamb, M. A. Smith, W. B. Weeks et al., "Publicly Reported Quality-of-Care Measures Influenced Wisconsin Physician Groups to Improve Performance," Health Affairs, March 2013 32(3):536–43.

Initial Report Suggest Providing Social Supports Leads to Lower Medical Costs

A review of seven programs that provide patients with social support, such as transportation or caregiver assistance, suggests that coordinated efforts to identify and meet the social needs of patients can lead to lower health care use and costs, and better outcomes for patients. For example, Senior Care Options—a Massachusetts program that coordinates the direct delivery of social support services for patients with chronic conditions and adults with disabilities—reported that hospital days per 1,000 members were just 55 percent of those generated by comparable patients not receiving the program's extended services. The authors note more research is required to determine which social service components yield desired outcomes for specific patient populations. G. Shier, M. Ginsburg, J. Howell et al., "Strong Social Support Services, Such as Transportation and Help for Caregivers, Can Lead to Lower Health Care Use and Costs," Health Affairs, March 2013 32(3):544–51.

Short and Long Hospice Stay Lower Medical Spending

A study of the impact of Medicare's hospice benefit on costs found the program saved $2,651 for each patient enrolled between 53 and 105 days before death, compared with a control group. Even higher savings were seen with more common, shorter enrollment periods: $2,650, $5,040, and $6,430 per patient enrolled 1–7, 8–14, and 15–30 days prior to death, respectively. The authors note that within all of these periods, hospice patients had significantly lower rates of hospital service use and in-hospital death than matched controls. A. S. Kelley, P. Deb, Q. Du et al., "Hospice Enrollment Saves Money for Medicare and Improves Care Quality Across a Number of Different Lengths-of-Stay," Health Affairs, March 2013 32(3):552–61. 

In ACOs, Retrospective Attribution is Advantageous to Providers

Researchers simulated the effects of two approaches to assigning patients to an accountable care organization (ACO): prospective attribution and retrospective, or performance-year, attribution. Their analysis suggests that performance-year attribution offers advantages to health care providers. Under prospective attribution, 17 percent of patients did not receive care from providers at their assigned ACO during the performance year, and 31 percent did not receive care from primary care physicians at their ACO. In contrast, performance-year attribution meant that 100 percent of patients received care at their ACO, and 81 percent saw a primary care physician at their ACO. V. A. Lewis, A. B. McClurg, J. Smith et al., "Attributing Patients to Accountable Care Organizations: Performance Year Approach Aligns Stakeholders' Interests," Health Affairs, March 2013 32(3):587–95.

EHR Use Improves Screening Rates and Other Measures of Ambulatory Care Quality

A study that sought to determine the effect of electronic health records (EHR) on ambulatory care quality in a community-based setting found that EHR use was associated with significantly higher quality of care for four of the measures: hemoglobin A1c testing in diabetes, breast cancer screening, chlamydia screening, and colorectal cancer screening. Effect sizes ranged from 3 to 13 percentage points per measure. The study examined ambulatory practices in the Hudson Valley of New York, with a median practice size of four physicians plans. L. M. Kern, Y. Barron, R. V. Dhopeshwarkar et al., "Electronic Health Records and Ambulatory Quality of Care," Journal of General Internal Medicine, April 2013 28(4):496–503.

Commentary: For ACOs, Need to Narrowly Define Population Health

The authors of this commentary stress the importance of carefully defining the term "population health" in the context of accountable care organizations to distinguish the practice of providing preventive care and chronic disease management to patients served by an ACO from efforts to improve the health of population in a geographic area. The latter depend not only on medical care, but also social and public health services. Suggesting ACOs are engaged in strategies to improve the health of a larger community may divert attention away from the need for social and public health services to address the socioeconomic determinants of health. D. J. Noble and L. P. Casalino, "Can Accountable Care Organizations Improve Population Health? Should They Try?" Journal of the American Medical Association, March 2013 309(11):1119–20. 

Mortality and Readmission Rates Not Linked for Certain Conditions

A study that sought to determine the relationship between publicly reported mortality and readmission rates for Medicare patients admitted to hospitals for acute myocardial infarction, heart failure, and pneumonia found that risk-standardized mortality rates and readmission rates were not associated for patients admitted with acute myocardial infarction or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure. The study demonstrates that performance on one of the quality measures does not control performance on the other, suggesting hospitals many need to pursue different strategies to perform well on both measures. H. M. Krumholz, Z. Lin, P. S. Keenan et al., "Relationship Between Hospital Readmission and Mortality Rates for Patients Hospitalized with Acute Myocardial Infarction, Heart Failure, or Pneumonia," Journal of the American Medical Association, February 2013 309(6):587–93. 

Readmission Reduction Program Needs Refinement, Authors Say

The authors of this commentary suggest that CMS adjust its hospital readmission measures to reflect socioeconomic status—for example by adding a patient's eligibility for Supplemental Security Income to risk adjustment models—to ensure that hospitals that disproportionately care for the most socially and clinically vulnerable patients are not unfairly penalized for having higher-than-expected readmission rates. The authors also suggest weighting readmission penalties according to the timing of the readmission such that readmissions occurring within the first few days of discharge incur a more substantial penalty than readmissions that occur four weeks later. The former may reflect poor care coordination while the latter are more likely due to the underlying severity of a patient's disease. K. E. Joynt and A K. Jha, "A Path Forward on Medicare Readmissions," New England Journal of Medicine, March 2013 368(13):1175–77.

Culture a Factor in Motivation to Engage in Practice Improvement

A study that sought to understand what motivates primary care practices to engage in practice improvement and identify external and internal facilitators and barriers to improvement found that culture, leadership priorities, values set by the physicians, and other factors influence whether primary care practices engage in improvement efforts. The authors also found primary care practices face conflicting pressures to engage in improvement and stick with the status quo by continuing to see patients every 15 minutes. D. G. Goldberg, S. S. Mick, A. J. Kulzel et al., "Why Do Some Primary Care Practices Engage in Practice Improvement Efforts Whereas Others Do Not?" Health Services Research, April 2013 48(2.1):398–416. 

Retail Clinics Disruptive to Primary Care in Some Respects But Not Others

A study that sought to assess the association between retail clinic use and receipt of primary care found that, upon developing new symptoms, patients who visited retail clinics were 25 percent less likely to make subsequent visits to primary care providers. By contrast, retail visits did not negatively affect preventive care and diabetes management. R. O. Reid, J. S. Ashwood, M. W. Friedberg et al., "Retail Clinic Visits and Receipt of Primary Care," Journal of General Internal Medicine, April 2013 28(4):504–12.

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