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Publications of Note

Positive and Inverse Relationships Between EMR Use and Quality Found
A study of the relationship between electronic medical record (EMR) features and quality found that having reminders for guideline-based interventions or screening tests was associated with lower odds of inappropriate urinalysis and of prescription of antibiotics for upper-respiratory tract infections, suggesting better quality. However, having a patient problem list was associated with higher odds of inappropriate prescribing for elderly patients. In addition blood pressure was less likely to be checked in offices with basic or fully functioning EMRs. C. J. Hsiao, J. A. Marsteller, and A. E. Simon, "Electronic Medical Record Features and Seven Quality of Care Measures in Physician Offices," American Journal of Medical Quality, Jan./Feb. 2014 29(1):44–52.

New Model of Payment Would Encourage High-Value Primary Care, Authors Say

The authors of this commentary recommend that Medicare create a new category of primary care provider to accelerate the use of care teams (including nurses, care managers, health educators, social workers, and pharmacists) and foster the development of the information infrastructure for delivering patient-centered, coordinated primary care. Under such a model, primary care practices would receive a blend of fee-for-service payments and monthly care management fees per beneficiary served and have the opportunity for shared savings—predicated on performance on measures of patient outcomes, care, and resource use. They also recommend that Medicare eliminate the deductible for patients using these practices, and reduce coinsurance obligations from 20 percent to 10 percent to encourage use of primary care services. R. J. Baron and K. Davis, "Accelerating the Adoption of High-Value Primary Care—A New Provider Type Under Medicare?" New England Journal of Medicine, Jan. 2014 370(2):99–101.

Exhaustion of Food Budgets May Account for Patterns of Hypoglycemia Among Poor with Diabetes
Using administrative data on inpatient admissions in California, researchers found that admissions for hypoglycemia were more common among low-income patients than among patients in high-income populations, and that these admissions increased by 27 percent in the last week of the month when food budgets are often exhausted. The authors conclude that food insecurity might be an important driver of health inequities. H. K. Seligman, A. F. Bolger, D. Guzman et al., "Exhaustion of Food Budgets at Month's End and Hospital Admissions for Hypoglycemia," Health Affairs, Jan. 2014 33(1):116–23.

Baseline Characteristics of Federal ACOs Outlined
A study of the structural and market characteristics of federal accountable care organizations (ACOs) for Medicare beneficiaries found that ACO patients were more likely than non-ACO patients to be older than age 80 and have higher incomes. ACO patients were also less likely than non-ACO patients to be black, covered by Medicaid, or disabled. The study also found the cost of care for ACO patients was slightly lower than that for non-ACO patients and slightly less than half of the ACOs included a participating hospital. Hospitals that were in ACOs were more likely than non-ACO hospitals to be large, teaching, and not-for-profit, although there was little difference in their performance on quality metrics, the researchers found. A. M. Epstein, A. J. Jha, E. J. Orav et al., "Analysis of Early Accountable Care Organizations Defines Patient, Structural, Cost, and Quality-of-Care Characteristics," Health Affairs, Jan. 2014 33(1):95–102.

Disease Management, Not Lifestyle Management, Saves PepsiCo Money

An evaluation of the cost impact of the lifestyle and disease management components of PepsiCo's wellness program, Healthy Living, found that seven years of continuous participation in the programs was associated with an average reduction of $30 in health care costs per member per month. However, looking at the two components separately, the researchers found that only the disease management component was associated with lower health care costs; those fell by $136 per member per month, driven by a 29 percent reduction in hospital admissions. The authors note workplace wellness programs may reduce health risks, delay or avoid the onset of chronic diseases, and lower health care costs for employees with manifest chronic disease, but employers and policymakers should not take the cost benefits of such programs for granted. J. P. Caloyeras, H. Liu, E. Exum et al., "Managing Manifest Diseases, But Not Health Risks, Saved PepsiCo Money Over Seven Years," Health Affairs, Jan. 2014 33(10):124–31.

Simulation Techniques Could Be Used to Improve Patients' and Caregivers' Understanding of Care Plans
To ensure that patients understand how to care for chronic health conditions and have the support they need for self-care, the author of this commentary recommends adopting the same simulation techniques now used to train medical students to test patients' and their caregivers' understanding of care plans before they leave a hospital or clinic. This may not only reinforce learning but also help physicians identify obstacles such as low health literacy and cognitive impairments that interfere with self-care, the author says. E. A. Coleman, "Extending Simulation Learning Experiences to Patients with Chronic Health Conditions," Journal of the American Medical Association, Jan. 2014 311(3):243–44.

Framework for Prioritizing the Use of Quality Metrics Suggested

A study designed to assess the impact of health care performance measures on quality and health disparities found that among 13 quality indicators included in the Agency for Healthcare Research and Quality's National Healthcare Quality and Disparities reports, seven accounted for 93 percent of benefits in quality-adjusted life years, while the remaining six account for only 7 percent of total benefits. More than one-third of the benefits accrued from increasing the percentage of diabetics with controlled blood pressure and slightly more than half could be obtained by perfecting implementation of blood pressure control and ensuring optimal foot care for adults with diabetes, they found. D. O. Meltzer and J. W. Chung, "The Population Value of Quality Indicator Reporting: A Framework for Prioritizing Health Care Performance Measures," Health Affairs, Jan. 2014 33(1):132–39.

High-Performing Hospitals Have Lower Readmission Rates Across Multiple Conditions
A study of Medicare beneficiaries who were readmitted within 30 days of a hospital admission for heart failure, acute myocardial infarction, or pneumonia found that the distribution of readmissions by diagnoses was similar across categories of hospital performance—with high-performing hospitals having fewer readmissions for all common diagnoses. The results suggest that strategies for lowering the risk of readmission globally rather than for specific diagnoses or time periods after hospital stay may be effective. K. Dharmarajan, A. F. Hsieh, Z. Lin et al., "Hospital Readmission Performance and Patterns of Readmission: Retrospective Cohort Study of Medicare Admissions," BMJ, Nov. 2013 347:f6571.

Handoff Bundle Associated with a Significant Reduction in Medical Errors and Preventable Adverse Events Among Hospitalized Children
Researchers sought to determine whether the introduction of a multifaceted handoff program was associated with reduced rates of medical errors and preventable adverse events among pediatric patients. They found that use of a resident handoff bundle—consisting of standardized communication and handoff training, a verbal mnemonic, and a new team handoff structure—reduced the number of medical errors from 33.8 to 18.3 per 100 admissions and reduced preventable adverse events from 3.3 to 1.5 per 100 admissions. Researchers also found fewer omissions of key handoff elements, especially on a unit that received a computerized handoff tool. A. J. Starmer, T. C. Sectish, D. W. Simon et al., "Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle," Journal of the American Medical Association, Dec. 4, 2013 310(21):2262–70.

Wide Variance in Treatment Costs Among Medicare Beneficiaries Tied to Population Health and Practice Patterns
A study of geographic variations in treatment costs for specific conditions among Medicare beneficiaries found the cost of episodes of care varied from 34 percent to 68 percent between the most and least expensive areas. The researchers also found that area hospitalization rates, surgery rates, and specialist involvement were associated with episode costs, but population health indicators were most related to total per-beneficiary costs. The authors conclude that population health appears to drive local per-beneficiary Medicare costs, whereas local practice patterns likely influence condition-specific episode costs. J. D. Reschovsky, J. Hadley, A. J. O'Malley et al., "Geographic Variations in the Cost of Treating Condition-Specific Episodes of Care Among Medicare Patients," Health Services Research, Feb. 2014 49(1):32–51.

Redesigned Workflows and Clinical Information Systems Combined with Self-Management Support Improves Kaiser's Performance on HEDIS Measures
In an effort to improve performance on Healthcare Effectiveness Data and Information Set (HEDIS) measures, Kaiser Permanente Southern California developed and implemented a comprehensive delivery system redesign that expanded and integrated existing clinical information systems, decision support, workflows, and self-management support. The program, which was designed to transform care for healthy members, those with chronic conditions, and those with multiple comorbidities, improved performance on 51 measures by 13 percent on average, outpacing changes in the HEDIS national percentiles for many measures. M. H. Kanter, G. Lindsay, J. Bellows et al., "Complete Care at Kaiser Permanente: Transforming Chronic and Preventive Care," Joint Commission Journal on Quality and Patient Safety, Nov. 2013 39(11):484–94.

Greater Integration of Behavioral and Medical Health Services Recommended
The authors of this article say financial integration of behavioral health and medical health services is needed to improve health outcomes for patients requiring both services. Existing methods of delivering these services—referring patients from medical offices to behavioral health ones and vice versa or adding behavioral health staff to primary care settings—are ineffective, they say. To improve outcomes, these services need to be more closely linked. Achieving integration will also require behavioral and medical professionals to develop an understanding of one another's practices. This may be achieved through integrated educational activities such as combined residencies, the authors say. R. Manderscheid and R. Kathol, "Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings," Annals of Internal Medicine, Jan. 2014 160(1):61–65.

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