Effect of Physician Participation in a Multi-element Health Information and Data Exchange Program on Chronic Illness Medication Adherence.

BACKGROUND: The Primary Care Information Project (PCIP) includes a network of more than 10,000 physicians across New York City focusing on improving the quality of patient care through the use of health information technology and data exchange. METHODS: We assessed adherence, defined as the percentage with a medication possession ratio (MPR) ≥80%, across 2 time periods for union members whose primary care providers participated in the PCIP compared with those whose providers did not participate. Using prescription claims data from 2008 and 2011, the MPR was calculated for disease-specific categories of drugs among patients with diabetes, hypertension, and both conditions. RESULTS: Greater improvements in the number of adherent members were observed for the PCIP patients with diabetes who were taking diabetes-specific medications (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.08-3.83 for PCIP, versus OR, 1.14; 95% CI, 0.81-1.60 for non-PCIP) and patients with diabetes who are taking lipid-controlling medications (OR, 1.64; 95% CI, 0.73-3.65 for PCIP versus OR, 0.85; 95% CI, 0.55-1.32 for non-PCIP). However, the magnitude and significance of these associations were diminished when practices providing reduced prescription co-pays were excluded from the analyses. CONCLUSION: Access to primary care providers participating in a public health initiative was associated with some improvement in medication adherence. However, reducing prescription co-pays may be a stronger factor for higher medication adherence among union members.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial.

IMPORTANCE: Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied. OBJECTIVE: To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative. DESIGN, SETTING, AND PARTICIPANTS: A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance. INTERVENTIONS: Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to both the intervention and control groups. MAIN OUTCOMES AND MEASURES: Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention. RESULTS: Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant. CONCLUSIONS AND RELEVANCE: Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00884013.

Early assessment of health care utilization among a workforce population with access to primary care practices with electronic health records.

This study assesses the health care costs and utilization among labor union members from 2008 to 2010 and compares whether members accessing primary care providers participating in a public health city program, the Primary Care Information Project (PCIP), had different health care usage or cost patterns. Using claims data, the number of hospital inpatient services utilized decreased by 16 per 100 members among those with chronic conditions accessing PCIP providers, whereas members seeing non-PCIP providers increased by 15 per 100 members. Access to providers participating in a population health initiative was associated with lower utilization of inpatient services and overall costs.

Patient experiences at primary care practices using electronic health records.

We assessed patient experiences before and one year after electronic health record (EHR) implementation among primary care practices in New York City. These practices represented an ethnically diverse population in lower-income, urban communities. Surveys, available in English, Spanish, and Chinese languages, were administered at 10 sites. Generally, patients reported positive responses during both periods. After EHR implementation, patients were more likely to want e-mail communication with their doctors' office. The 70% of patients with Internet access were generally more satisfied with their experience and more likely to recognize benefits of EHRs. However, older patients and those with lower education levels or chronic diseases were significantly less likely than their counterparts to use the Internet. Therefore, disparities in Internet access could potentially lead to unequal access and use of healthcare if not addressed. Practices should routinely record patient communication preferences within the EHR, to tailor communications and improve patient experiences.

Tracking the delivery of prevention-oriented care among primary care providers who have adopted electronic health records.

The Primary Care Information Project is a New York City initiative aimed at improving population health through the improved delivery of preventive care. It has assisted with the adoption of a fully functional electronic health record (EHR) in over 300 primary care practices. Practices with EHRs automatically transmit summary data that can be used to track population health indicators for recommended preventive care. Early analysis, focusing on small practices with fewer than 10 providers serving Medicaid and uninsured populations, showed increases in the delivery of recommended services of 0.1-2.4% per month (p ≤ 0.05). However, measurement of preventive care across this population is limited by some inconsistency of data transmission. This study shows that EHRs can be used to track the delivery of recommended preventive care across small primary care practices serving lower income communities in which few data are generally available for assessing population health.

Associations between ozone and daily mortality: analysis and meta-analysis.

BACKGROUND: There is ample evidence that short-term ozone exposure is associated with transient decrements in lung functions and increased respiratory symptoms, but the short-term mortality effect of such exposures has not been established. METHODS: We conducted a review and meta-analysis of short-term ozone mortality studies, identified unresolved issues, and conducted an additional time-series analysis for 7 U.S. cities (Chicago, Detroit, Houston, Minneapolis-St. Paul, New York City, Philadelphia, and St. Louis). RESULTS: Our review found a combined estimate of 0.39% (95% confidence interval = 0.26-0.51%) per 10-ppb increase in 1-hour daily maximum ozone for the all-age nonaccidental cause/single pollutant model (43 studies). Adjusting for the funnel plot asymmetry resulted in a slightly reduced estimate (0.35%; 0.23-0.47%). In a subset for which particulate matter (PM) data were available (15 studies), the corresponding estimates were 0.40% (0.27-0.53%) for ozone alone and 0.37% (0.20-0.54%) with PM in model. The estimates for warm seasons were generally larger than those for cold seasons. Our additional time-series analysis found that including PM in the model did not substantially reduce the ozone risk estimates. However, the difference in the weather adjustment model could result in a 2-fold difference in risk estimates (eg, 0.24% to 0.49% in multicity combined estimates across alternative weather models for the ozone-only all-year case). CONCLUSIONS: Overall, the results suggest short-term associations between ozone and daily mortality in the majority of the cities, although the estimates appear to be heterogeneous across cities.

Contribution of respiratory disease to nonrespiratory mortality associations with air pollution.

Many time series studies have found that individuals with primary cardiac conditions were susceptible to the adverse effects associated with increased ambient particle levels. However, the mechanism(s) of these associations is not yet understood. In this study, we evaluate whether individuals with nonrespiratory primary causes of death who also had contributing respiratory causes listed on their death certificates were more affected by air pollution, as compared with those not having contributing respiratory conditions. Short-term associations between ambient particulate matter (10 microm or less in aerodynamic diameter) and mortality were modeled in New York City for the years 1985-1994. It was observed that among those 75 years or more, those with contributing respiratory disease had higher relative risks (95% confidence intervals) calculated per interquartile range, as compared with those without contributing respiratory disease for both circulatory deaths (relative risk = 1.066 [1.027-1.106] versus 1.022 [1.008-1.035]) and cancer deaths (relative risk = 1.129 [1.041-1.225] versus 1.025 [1.000-1.050]). However, this pattern of association was not observed for those who were less than 75 years old. The results of this study suggest that past studies may have underestimated the role of respiratory disease in pollution-mortality associations, especially among older adults.