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Publications of Note

Medication Discontinuation Orders Not Consistently Executed by Pharmacies

A study that sought to determine the extent to which pharmacies dispensed medications for which a physician had issued an electronic discontinuation order found that 1.5 percent of the discontinued prescriptions had been refilled once, on average, during a 12-month follow-up period. A manual chart review of 416 medication-dispensing events that were predefined as high risk found potential harm in 12 percent of the cases, including clinical reactions, laboratory abnormalities, duplicated medication classes dispensed, and potential allergic reactions. The authors recommend that electronic health records be used to facilitate better communication between providers and pharmacies and improve medication safety. A. S. Allen and T. D. Sequist, "Pharmacy Dispensing of Electronically Discontinued Medications," Annals of Internal Medicine, Nov. 2012 157(10):7005–5. 

Open Medical Records Popular with Patients

A yearlong program that enabled patients to review their primary care physicians' notes found that patients accessed visit notes frequently, and a large majority reported clinically relevant benefits. Across three sitesBeth Israel Deaconess Medical Center in Massachusetts, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Washington State—between 77 percent and 87 percent of patients reported that open notes helped them feel more in control of their care; 60 percent to 78 percent of those taking medications reported increased medication adherence; and 20 percent to 42 percent reported sharing notes with others. At the end of the experimental period, 99 percent of patients wanted open notes to continue and no doctor elected to stop. T. Delbanco, J. Walker, S. K. Bell et al., "Inviting Patients to Read Their Doctors' Notes: A Quasi-Experimental Study and a Look Ahead," Annals of Internal Medicine, Oct. 2012 157(7):461–70. 

EHR Use Correlated with Diabetes Control

A study examining the association between the use of commercially available and certified electronic health records, or EHRs, and clinical care processes and disease control in patients with diabetes found that the use of an EHR was associated with improved drug treatment intensification (augmenting an initial prescription with one or more other drugs to make the treatment more effective), better monitoring, and better physiologic control, as well as with greater improvements among patients with worse control and less testing in patients already meeting recommended glycemic and lipid targets. M. Reed, J. Huang, I. Graetz et al., "Outpatient Electronic Health Records and the Clinical Care and Outcomes of Patients with Diabetes Mellitus," Annals of Internal Medicine, Oct. 2012 157(7):482–9. 

ACOs Likely to Encounter Same Challenges as 1990s Integrated Delivery Networks

The authors of this commentary note that accountable care organizations (ACOs) may encounter the same challenges that integrated delivery networks did in the 1990s when implementing incentives and disease management programs to improve the quality and increase the efficiency of care. They note that with ACOs, new coordination methods and information technology are proving more complicated and expensive to implement than anticipated, providers may lack the ability to implement these mechanisms, and primary care providers are in short supply. Success may depend on targeting specific populations, such as people with multiple chronic conditions who need coordinated care, the authors note. L. R. Burns and M. V. Pauly, "Accountable Care Organizations May Have Difficulty Avoiding the Failures of Integrated Delivery Networks of the 1990s," Health Affairs, Nov. 2012 31(11):2407–16. 

Change in Physician Mindset Critical to Medical Home Transformation

The authors of this article say their research indicates that four characteristics of small, independent physician practices inhibit their transformation to patient-centered medical homes. These include being extremely physician-centric, lacking meaningful communication among physicians, being dominated by authoritarian leadership behavior, and being underserved by midlevel clinicians. The authors suggest that in addition to payment reform, a shift in the mindset of primary care physicians is necessary to ensure practice transformation. P. A. Nutting, B. F. Crabtree, and R. R. McDaniel, "Small Primary Care Practices Face Four Hurdles—Including a Physician-Centric Mind-Set—in Becoming Medical Homes," Health Affairs, Nov. 2012 31(11):2417–22. 

New Methodology for Measuring Quality Proposed

The authors of this article recommend using a "Global Outcomes Score," or GO Score, in place of process measures to assess the quality of health care delivered. Unlike current performance measures, the GO Score focuses on expected outcomes and does not mandate particular processes or treatment goals. The GO Score is calculated by comparing 1) the outcomes were no care received, 2) the outcomes under current care, and 3) the outcomes were target care delivered to reveal the extent to which current care fails to meet treatment potential. To illustrate the methodology, the authors examined data on blood pressure and cholesterol care for patients at risk of hardening of the arteries. They found that under current care, clinicians avoided only 40 percent of the myocardial infarctions and strokes that would be eliminated if target care were provided. D. M. Eddy, J. Adler, and M. Morris, "The 'Global Outcomes Score': A Quality Measure, Based on Health Outcomes, That Compares Current Care to a Target Level of Care," Health Affairs, Nov. 2012 31(11):2441–50. 

Study Finds Less Experienced Physicians Have Higher Costs Than More Experienced Physicians

A study of health plan claims of physicians in Massachusetts found that physicians with fewer than 10 years of experience had 13.2 percent higher overall costs compared with physicians with 40 or more years of experience. The authors found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, or size of group in which the physician practices. They note the more costly practice style of newly trained physicians may be a driver of rising health care costs overall. A. Mehotra, R. O. Reid, J. L. Adams et al., "Physicians with the Least Experience Have Higher Cost Profiles Than Do Physicians with the Most Experience," Health Affairs, Nov. 2012 31(11):2453–63. 

ACOs Must Use a Multifaceted Approach to Meet Cost Targets in Medicare's Shared Savings Program

Using a simulation model to analyze the effects of Medicare's Shared Savings Program on a population of patients with type 2 diabetes, the authors found that a 10-percentage-point improvement in performance on diabetes quality measures would reduce Medicare costs only by 1 percent or less. After the costs of performance improvement, such as additional tests or visits, are accounted for, the savings would decrease or become cost increases. To achieve greater savings, accountable care organizations will have to lower costs by other means, such as through improved use of information technology and care coordination, the authors suggest. D. M. Eddy and R. Shah, "A Simulation Shows Limited Savings from Meeting Quality Targets Under the Medicare Shared Savings Program," Health Affairs, Nov. 2012 31(11):2554–62. 

Reducing Surgical Complications Creates Financial Ones for Hospitals

Programs designed to reduce complications following surgery, which benefit patients and payers, can reduce hospital revenues, as reimbursements to treat complications decrease and fixed cost structure remains in place. The revenue reduction may be offset if the hospital is able to increase surgical volume, but some hospitals including rural ones may not be able to do so. The authors note that gainsharing agreements that enable hospitals to share in the savings that accrue from reduced complications may encourage hospitals to pursue risk-reduction strategies. D. C. Krupka, W. S. Sandberg, and W. B. Weeks, "The Impact on Hospitals of Reducing Surgical Complications Suggests Many Will Need Shared Savings Programs with Payers," Health Affairs, Nov. 2012 31(11):2571–78. 

Methods of Facilitating After-Hours Care Outlined

A study that sought to identify promising means of providing after-hours care found five models that varied by patients' preferences and needs, the local health care market, and financial compensation. The authors, who interviewed staff at primary care practices in 16 states, also outlined the challenges of implementing after-hours programs, for instance in areas where small, independent practices are the norm. They noted shared electronic health records facilitated communication between daytime providers and after-hours providers. A. S. O'Malley, D. Samuel, A. M. Bond et al., "After-Hours Care and its Coordination with Primary Care in the U.S.," Journal of General Internal Medicine, Nov. 2012 27(1):1406–15. 

Challenges of CMS' Bundled Payment Program

A commentary in the New England Journal of Medicine notes that the Centers for Medicare and Medicaid Services' (CMS) Bundled Payments for Care Improvement Initiative, which rewards providers for taking financial responsibility for Medicare beneficiaries across a full continuum of services, may as currently structured penalize hospitals due to random and systematic variation in the severity of illness of their patients. Using Medicare claims data, the authors also found that Medicare spends as much or more in the 90 days after discharge as it spends for the initial hospitalization. The data also show wide variation in average post–acute care spending. Hospitals with post–acute care spending above the median for any particular episode type spent, on average, about 40 percent more than hospitals with spending below the median. The gap is significant because the program will require those exceeding the spending target to return the excess amount to CMS. R. Mechanic and C. Tompkins, "Lessons Learned Preparing for Medicare Bundled Payments," New England Journal of Medicine, Nov. 2012 367(20):1873–5. 

Limited Impact of Medicare's P4P Demonstration

A study designed to evaluate the effects of Medicare's hospital pay-for-performance (P4P) demonstration project on hospital revenues, costs, and margins found no significant effect. The authors of the study, which examined claims for patients hospitalized for heart failure, say the results emphasize the need for a better understanding of the financial implications of pay-for-performance programs on providers and payers. G. B. Kruse, D. Polsky, E. A. Stuart et al., "The Impact of Hospital Pay-for-Performance on Hospital and Medicare Costs," Health Services Research, Dec. 2012 47(6):2128–36. 

Quality of Care at Community Health Centers Comparable to National Averages

A study examining clinical quality of care delivered at community health centers as well as the characteristics of centers that achieved high performance on measures of prenatal care, childhood immunization completion, Pap tests, low birth weight, and hypertension and diabetes control found that clinical care quality and outcomes among health centers were generally comparable to national averages. On some measures, centers with more uninsured patients were less likely to do well, while centers with more physicians and enabling service providers were more likely to do well. L. Shi, L. A. Lebrun, J. Zhu et al., "Clinical Quality Performance in U.S. Health Centers," Health Services Research, Dec. 2012 47(6):2225–49. 

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