How to Get Better Care with Lower Costs? See the Person, Not the Patient.

The U.S. health system perceives people as "patients" almost exclusively as they enter and exit the healthcare system, but with this emphasis on context, have we lost sight of the people who should be in the foreground of care? Does such a view impede care effectiveness and efficiency? How can we shift our frame of reference moving forward? To foster this needed conceptual shift, a group of national thought-leaders convened by the American Geriatrics Society (AGS) defined "person-centered care" to reorient the perspective toward individuals remaining in the center of pursuing high-quality care. This article explores how a person-centered care approach can improve healthcare effectiveness and efficiency, particularly for older adults with heightened health and daily living needs, and healthcare costs. The process for supporting a person-centered program is outlined, three critical indicators that define person-centered quality are highlighted, and several models that embrace the person-centered paradigm are briefly noted. Although there is no one-size-fits-all schematic, how and why overall success entails fidelity to essential elements of person-centered programs as the AGS expert panel identified is explained.

Targeting primary care referrals to smoking cessation clinics does not improve quit rates: implementing evidence-based interventions into practice.

OBJECTIVE: To evaluate the impact of a locally adapted evidence-based quality improvement (EBQI) approach to implementation of smoking cessation guidelines into routine practice. DATA SOURCES/STUDY SETTING: We used patient questionnaires, practice surveys, and administrative data in Veterans Health Administration (VA) primary care practices across five southwestern states. STUDY DESIGN: In a group-randomized trial of 18 VA facilities, matched on size and academic affiliation, we evaluated intervention practices' abilities to implement evidence-based smoking cessation care following structured evidence review, local priority setting, quality improvement plan development, practice facilitation, expert feedback, and monitoring. Control practices received mailed guidelines and VA audit-feedback reports as usual care. DATA COLLECTION: To represent the population of primary care-based smokers, we randomly sampled and screened 36,445 patients to identify and enroll eligible smokers at baseline (n=1,941) and follow-up at 12 months (n=1,080). We used computer-assisted telephone interviewing to collect smoking behavior, nicotine dependence, readiness to change, health status, and patient sociodemographics. We used practice surveys to measure structure and process changes, and administrative data to assess population utilization patterns. PRINCIPAL FINDINGS: Intervention practices adopted multifaceted EBQI plans, but had difficulty implementing them, ultimately focusing on smoking cessation clinic referral strategies. While attendance rates increased (p<.0001), we found no intervention effect on smoking cessation. CONCLUSIONS: EBQI stimulated practices to increase smoking cessation clinic referrals and try other less evidence-based interventions that did not translate into improved quit rates at a population level.

Assessing the structure of smoking cessation care in the Veterans Health Administration.

PURPOSE: National smoking cessation practice guidelines offer recommendations regarding the processes and structure of care. Facilities routinely measure the processes of care but not the structure of care. This pilot study assessed the structure of smoking cessation care at Veterans Health Administration facilities. METHODS: Key informants at 18 sites completed a brief checklist survey adapted from national smoking cessation guidelines. Responses were compared with detailed site surveys. RESULTS: Guideline adherence was seen in identifying smokers and treating inpatient smokers. Areas of low adherence include offering incentives and defining staff responsibilities. The checklist survey showed poor correspondence with the detailed survey, with low agreement on systematic screening (kappa = .21) and higher agreement on primary care prescribing authority (kappa = .53). DISCUSSION: This pilot survey provides a potential rapid method for assessing adherence to systems recommendations from the national smoking cessation guidelines. The relatively low agreement with a more detailed survey suggests that the two surveys may have been measuring different aspects of smoking cessation care.

Modifying provider behavior: a low-tech approach to pharmaceutical ordering.

OBJECTIVE: To determine if a clinically structured, paper-based prescription form can modify pharmaceutical prescribing behavior without restricting physician freedom to select the most appropriate medication for an individual patient. DESIGN: Uncontrolled, nonrandomized, time series design. SETTING: The urgent care clinic of a university-affiliated, county-supported hospital that provides care for underserved, vulnerable populations. PATIENTS: Patients (N = 2189) who had a prescription written at the intervention site during the study. INTERVENTION: Four-phase interventions lasting 2 weeks each, with a washout period between each phase, consisting of: (1). collection of baseline data utilizing the traditional prescription blank, (2). introduction of the pre-formatted prescription form, (3). use of the pre-formatted prescription form with medication cost added, and (4). pre-formatted prescription form with target drug (ranitidine) removed. MEASUREMENTS AND MAIN RESULTS: Physicians were less likely to prescribe ranitidine compared to cimetidine after the introduction of the cost information (P <.01) and again after the removal of ranitidine from the pre-formatted prescription form (P <.001). CONCLUSIONS: A structured, paper-based prescription order form can shift prescribing practices without inhibiting physicians' ordering freedom.