Improving Regional Blood Pressure Control: a Positive Deviance Tiered Intensity Approach.

BACKGROUND: Accelerated translation of real-world interventions for hypertension management is critical to improving cardiovascular outcomes and reducing disparities. OBJECTIVE: To determine whether a positive deviance approach would improve blood pressure (BP) control across diverse health systems. DESIGN: Quality improvement study using 1-year cross sections of electronic health record data over 5 years (2013-2017). PARTICIPANTS: Adults ≥ 18 with hypertension with two visits in 2 years with at least one primary care visit in the last year (N = 114,950 at baseline) to a primary care practice in Better Health Partnership, a regional health improvement collaborative. INTERVENTIONS: Identification of a "positive deviant" and dissemination of this system's best practices for control of hypertension (i.e., accurate/repeat BP measurement; timely follow-up; outreach; standard treatment algorithm; and communication curriculum) using 3 different intensities (low: Learning Collaborative events describing the best practices; moderate: Learning Collaborative events plus consultation when requested; and high: Learning Collaborative events plus practice coaching). MAIN MEASURES: We used a weighted linear model to estimate the pre- to post-intervention average change in BP control (< 140/90 mmHg) for 35 continuously participating clinics. KEY RESULTS: BP control post-intervention improved by 7.6% [95% confidence interval (CI) 6.0-9.1], from 67% in 2013 to 74% in 2017. Subgroups with the greatest absolute improvement in BP control included Medicaid (12.0%, CI 10.5-13.5), Hispanic (10.5%, 95% CI 8.4-12.5), and African American (9.0%, 95% CI 7.7-10.4). Implementation intensity was associated with improvement in BP control (high: 14.9%, 95% CI 0.2-19.5; moderate: 5.2%, 95% CI 0.8-9.5; low: 0.2%, 95% CI-3.9 to 4.3). CONCLUSIONS: Employing a positive deviance approach can accelerate translation of real-world best practices into care across diverse health systems in the context of a regional health improvement collaborative (RHIC). Using this approach within RHICs nationwide could translate to meaningful improvements in cardiovascular morbidity and mortality.

Adoption of Health System Innovations: Evidence of Urban-Rural Disparities from the Ohio Primary Care Marketplace.

BACKGROUND: Accountable care organizations (ACOs), patient-centered medical homes (PCMHs), and the meaningful use of electronic health records (EHRs) generated particular attention during the last decade. Translating these reforms into meaningful increases in population health depends on improving the quality and clinical integration of primary care providers (PCPs). However, if these innovations spread more quickly among PCPs in urban and wealthier areas, then they could potentially worsen existing geographic disparities in health outcomes. OBJECTIVE: To determine the market penetration of Medicare Shared Savings Program (MSSP) ACOs, PCMHs, and the meaningful use of EHRs among PCPs across urban and rural counties in Ohio. DESIGN: Retrospective, observational study of the percent of PCPs in a county who are affiliated with PCMH, ACO, and meaningful use (MU) of EHR. PARTICIPANTS: PCPs in all of Ohio's 88 counties from 2011 to 2015. MAIN MEASURES: Primary care market penetration of ACO, PCMH, and meaningful use of EHR KEY RESULTS: In 2015, the Ohio primary care market penetration of PCMH was 23.4%, ACO was 27.7%, MU stage 1 was 55.8%, and MU stage 2 was 26.6%. During the study period, PCMH and ACO market penetration increased faster in urban counties relative to rural counties, and market penetration of meaningful use of EHR increased faster in rural counties. CONCLUSIONS: Market penetration of PCMH and ACOs increased faster in urban markets compared to rural markets. However, the adoption of EHRs increased faster in rural markets. The results are a cause for optimism as well as a call to action: although recent efforts to increase PCMH and ACO adoption were less effective among the rural population in Ohio, federal programs to accelerate adoption of EHRs were overwhelmingly successful in rural areas.

Association Of A Regional Health Improvement Collaborative With Ambulatory Care-Sensitive Hospitalizations.

Although regional health improvement collaboratives have been adopted nationwide to improve primary care quality, their effects on avoidable hospitalizations and costs remain unclear. We quantified the association of the Better Health Partnership, a primary care-led regional health improvement collaborative operating in Cuyahoga County, Ohio (Cleveland and surrounding suburbs), with hospitalization rates for ambulatory care-sensitive conditions. The partnership uses a positive deviance approach to identify, disseminate publicly, and accelerate adoption of best practices for care of patients with diabetes, heart failure, and hypertension. Using a difference-in-differences approach, we compared rates of hospitalizations for ambulatory care-sensitive conditions in six Ohio counties before (2003-08) and after (2009-14) the establishment of the partnership. Age- and sex-adjusted hospitalization rates for targeted ambulatory care-sensitive conditions in Cuyahoga County declined significantly more than the rates in the comparator counties in 2009-11 (106 fewer hospitalizations per 100,000 adult residents) and 2012-14 (91 fewer hospitalizations). We estimated that 5,746 hospitalizations for ambulatory care-sensitive conditions were averted in 2009-14, leading to cost savings of nearly $40 million.

Patient portals and broadband internet inequality.

BACKGROUND: Patient portals have shown potential for increasing health care quality and efficiency. Internet access and other factors influencing patient portal use could worsen health disparities. METHODS: Observational study of adults with 1 or more visits to the outpatient clinics of an urban public health care system from 2012 to 2015. We used mixed effects logistic regression to evaluate the association between broadband internet access and (1) patient portal initiation (whether a patient logged in at least 1 time) and (2) messaging, controlling for demographic and neighborhood characteristics. RESULTS: There were 243 248 adults with 1 or more visits during 2012-2015 and 70 835 (29.1%) initiated portal use. Portal initiation was 34.1% for whites, 23.4% for blacks, and 23.8% for Hispanics, and was lower for Medicaid (26.5%), Medicare (23.4%), and uninsured patients (17.4%) than commercially insured patients (39.3%). In multivariate analysis, both initiation of portal use (odds ratio [OR] = 1.24 per quintile, 95% confidence interval [CI], 1.23-1.24, P < .0001) and sending messages to providers (OR = 1.15, 95%CI, 1.09-1.14, P < .0001) were associated with neighborhood broadband internet access. CONCLUSIONS: The majority of adults with outpatient visits to a large urban health care system did not use the patient portal, and initiation of use was lower for racial and ethnic minorities, persons of lower socioeconomic status, and those without neighborhood broadband internet access. These results suggest the emergence of a digital divide in patient portal use. Given the scale of investment in patient portals and other internet-dependent health information technologies, efforts are urgently needed to address this growing inequality.

MetroHealth Care Plus: Effects Of A Prepared Safety Net On Quality Of Care In A Medicaid Expansion Population.

Studies of Medicaid expansion have produced conflicting results about whether the expansion is having a positive impact on health and the cost and efficiency of care delivery. To explore the issue further, we examined MetroHealth Care Plus, a Centers for Medicare and Medicaid Services (CMS) waiver program in Ohio composed of three safety-net organizations that enrolled 28,295 uninsured poor patients in closed-panel care during 2013. All participating organizations used electronic health records and patient-centered medical homes, publicly reported performance in a regional health improvement collaborative, and accepted a budget-neutral cap approved by CMS. We compared changes between 2012 and 2013 in achieving quality standards for diabetes and hypertension among 3,437 MetroHealth Care Plus enrollees to changes among 1,150 patients with the same conditions who remained uninsured in both years. Compared to continuously uninsured patients with diabetes, MetroHealth Care Plus enrollees with diabetes improved significantly more on composite standards of care and intermediate outcomes. Among enrollees with hypertension, blood pressure control improvements were insignificantly larger than those in the continuously uninsured group with hypertension. Across all 28,295 enrollees, 2013 total costs of care were 28.7 percent below the budget cap, providing cause for optimism that a prepared safety net can meet the challenges of Medicaid expansion.

Use and perceived value of health information exchange: one public healthcare system's experience.

OBJECTIVES: To describe health information exchange (HIE) use and providers' perceptions of value in a public healthcare system using a commercial electronic health record (EHR). STUDY DESIGN: Observational study of HIE implementation and cross-sectional provider survey. METHODS: We identified characteristics (age, gender, race/ethnicity, insurance type, comorbid conditions) and the care setting (primary care; emergency department [ED] or inpatient care; or specialty care) for patients with and without HIE. Associations between patient characteristics and HIE were examined using a multivariate logistic regression. Provider perceptions were assessed via confidential survey. RESULTS: During its first 14 months, 11,960 HIEs occurred among 9399 patients. Rates of HIE use were 13/1000 visits overall (20/1000 in primary care, 36/1000 in the ED/inpatient setting, and 5/1000 in specialty settings [P <.001]). Patients with HIE were older, more often female, African American, had more chronic conditions, and more often had Medicaid or Medicare insurance (P <.001). HIE was used least among commercially insured (odds ratio, 0.78, 95% confidence interval,0.73-0.83, compared with uninsured). Among the 18% (74/412) of survey respondents, 93% "disagreed/strongly disagreed" that obtaining consent was difficult and 97% reported no patient refusals. Respondents "agreed/strongly agreed" that HIE fostered more efficient care (93%), saved time (85%), decreased laboratory (84%) and imaging (74%) use, and 15% stated that HIE prevented an unnecessary admission. CONCLUSION: Early HIE use varied by care setting, patient characteristics, and insurance. Providers perceived HIE acceptable to patients, and helpful in avoiding redundant testing and unnecessary hospitalizations. Lower HIE use among commercially insured patients reinforces concerns that financial incentives may inhibit adoption.

Electronic health records and quality of diabetes care.

BACKGROUND: Available studies have shown few quality-related advantages of electronic health records (EHRs) over traditional paper records. We compared achievement of and improvement in quality standards for diabetes at practices using EHRs with those at practices using paper records. All practices, including many safety-net primary care practices, belonged to a regional quality collaborative and publicly reported performance. METHODS: We used generalized estimating equations to calculate the percentage-point difference between EHR-based and paper-based practices with respect to achievement of composite standards for diabetes care (including four component standards) and outcomes (five standards), after adjusting for covariates and accounting for clustering. In addition to insurance type (Medicare, commercial, Medicaid, or uninsured), patient-level covariates included race or ethnic group (white, black, Hispanic, or other), age, sex, estimated household income, and level of education. Analyses were conducted separately for the overall sample and for safety-net practices. RESULTS: From July 2009 through June 2010, data were reported for 27,207 adults with diabetes seen at 46 practices; safety-net practices accounted for 38% of patients. After adjustment for covariates, achievement of composite standards for diabetes care was 35.1 percentage points higher at EHR sites than at paper-based sites (P<0.001), and achievement of composite standards for outcomes was 15.2 percentage points higher (P=0.005). EHR sites were associated with higher achievement on eight of nine component standards. Such sites were also associated with greater improvement in care (a difference of 10.2 percentage points in annual improvement, P<0.001) and outcomes (a difference of 4.1 percentage points in annual improvement, P=0.02). Across all insurance types, EHR sites were associated with significantly higher achievement of care and outcome standards and greater improvement in diabetes care. Results confined to safety-net practices were similar. CONCLUSIONS: These findings support the premise that federal policies encouraging the meaningful use of EHRs may improve the quality of care across insurance types.

Care fragmentation and emergency department use among complex patients with diabetes.

OBJECTIVE: To evaluate the association between patterns of fragmented care and emergency department (ED) use among adult patients with diabetes and chronic kidney disease. STUDY DESIGN: Observational study in an open healthcare system. METHODS: The study sample included patients with diabetes and chronic kidney disease (mean estimated glomerular filtration rate, 20-60 mL/min) and with an established primary care provider. Dispersion of care was defined by a fragmentation of care index (range, 0-1), with zero reflecting all care in 1 outpatient clinic and 1 reflecting each visit at a different clinic site. We used a negative binomial model to estimate the influence of fragmentation on ED use after adjusting for patient demographic characteristics, insurance, diabetes control, and number of comorbidities; results are reported as incidence rate ratios and associated 95% confidence intervals (CIs). The main outcome measure was the number of ED visits from 2002 to 2003. RESULTS: Of 3873 patients with diabetes having an established primary care provider, 623 (16.1%) had chronic kidney disease and comprised the final study sample. On average, patients made 19.0 (95% CI, 18.5-20.4) outpatient visits and 1.2 (95% CI, 1.1-1.4) ED visits over the 2-year period. The median fragmentation of care index was 0.48; 14.3% of subjects had a fragmentation of care index of zero. In the adjusted model, a 0.1-U increase in the fragmentation of care index was associated with a 15% increase in the number of ED visits (incidence rate ratio, 1.15; 95% CI, 1.09-1.21). CONCLUSIONS: The posited benefits of specialist referrals among patients with complex diabetes may be partially negated by care fragmentation. Better models for care coordination and stronger evidence of the marginal benefits of referrals are needed.

Using electronic medical records to measure and improve performance.

Clinical performance measurement and public reporting are taking center stage nationwide, linked to transparency initiatives and incentive systems that reward physicians for meeting endorsed quality standards. While electronic medical records (EMRs) are increasingly available to measure and improve quality of care, performance measurement continues to be dominated by the use of insurance claims. Limitations to claims-based measurement include challenges in assigning attribution of care to specific physicians, inefficient and incomplete sampling methods, and the coarseness of measures frequently available to insurers. Practice improvement using claims-based approaches is further limited by the inability to provide timely and specific feedback to physicians and their patients. Finally, in claims-based approaches, care is not measured for the 47 million uninsured patients in the United States. In the current presentation I describe how these limitations are being addressed using EMRs, highlighting the design and selected preliminary results of a large trial to improve the care of patients with diabetes.

Electronic medical record-assisted design of a cluster-randomized trial to improve diabetes care and outcomes.

BACKGROUND: Electronic medical records (EMRs) have the potential to facilitate the design of large cluster-randomized trials (CRTs). OBJECTIVE: To describe the design of a CRT of clinical decision support to improve diabetes care and outcomes. METHODS: In the Diabetes Improvement Group-Intervention Trial (DIG-IT), we identified and balanced preassignment characteristics of 12,675 diabetic patients cared for by 147 physicians in 24 practices of 2 systems using the same vendor's EMR. EMR-facilitated disease management was system A's experimental intervention; system B interventions involved patient empowerment, with or without disease management. For our sample, we: (1) identified characteristics associated with response to interventions or outcomes; (2) summarized feasible partitions of 10 system A practices (2 groups) and 14 system B practices (3 groups) using intra-cluster correlation coefficients (ICCs) and standardized differences; (3) selected (blinded) partitions to effectively balance the characteristics; and (4) randomly assigned groups of practices to interventions. RESULTS: In System A, 4,306 patients, were assigned to 2 groups of practices; 8,369 patients in system B were assigned to 3 groups of practices. Nearly all baseline outcome variables and covariates were well-balanced, including several not included in the initial design. DIG-IT's balance was superior to alternative partitions based on volume, geography or demographics alone. CONCLUSIONS: EMRs facilitated rigorous CRT design by identifying large numbers of patients with diabetes and enabling fair comparisons through preassignment balancing of practice sites. Our methods can be replicated in other settings and for other conditions, enhancing the power of other translational investigations.

Redirecting patients to improve stroke outcomes: implications of a volume-based approach in one urban market.

BACKGROUND: The designation of primary stroke centers may result in patients being redirected from their usual source of care, although there is little evidence that these centers would result in better outcomes or lower costs. An alternative approach could direct patients to hospitals treating greater volumes of stroke patients. OBJECTIVES: We sought to estimate the effect of hospital stroke volume on patient mortality and costs in a regional hospital market and to analyze the implications of hypothetical volume-based referral policies in that market, including the effects of patient-hospital distance. METHODS: Using a retrospective cohort, we studied 12,150 Medicare patients admitted for acute stroke to 1 of 29 hospitals in Greater Cleveland during a 7-year period. The primary outcome was risk-adjusted 30-day mortality. Secondary outcomes included log hospital costs and discharge destination. The primary measure of volume was average annual number of stroke patients; patient distance to the nearest hospital was approximated using patient zip code and hospital address data. RESULTS: Overall 30-day mortality was 14.9%. For each 100-patient increase in hospitals' annual stroke volume, risk-adjusted mortality declined 0.9 percentage points (odds ratio = 0.90; 95% confidence interval = 0.82-0.98; P < 0.02) with no significant difference in hospital costs. For each 1-mile increase in patient distance to nearest hospital, mortality increased 0.6 percentage points (odds ratio = 1.07; 95% confidence interval = 1.03-1.11; P < 0.01). Only 3 of 29 hospitals (10.3%) exceeded the highest plausible threshold (250 strokes/year), redirecting 81.4% of patients for a net reduction in mortality of 0.4%; lower thresholds would redirect fewer patients but have negligible effects on mortality. CONCLUSIONS: Our findings fail to support redirecting acute stroke patients based on hospital stroke volume.

Overcoming bias in estimating the volume-outcome relationship.

OBJECTIVE: To examine the effect of hospital volume on 30-day mortality for patients with congestive heart failure (CHF) using administrative and clinical data in conventional regression and instrumental variables (IV) estimation models. DATA SOURCES: The primary data consisted of longitudinal information on comorbid conditions, vital signs, clinical status, and laboratory test results for 21,555 Medicare-insured patients aged 65 years and older hospitalized for CHF in northeast Ohio in 1991-1997. STUDY DESIGN: The patient was the primary unit of analysis. We fit a linear probability model to the data to assess the effects of hospital volume on patient mortality within 30 days of admission. Both administrative and clinical data elements were included for risk adjustment. Linear distances between patients and hospitals were used to construct the instrument, which was then used to assess the endogeneity of hospital volume. PRINCIPAL FINDINGS: When only administrative data elements were included in the risk adjustment model, the estimated volume-outcome effect was statistically significant (p=.029) but small in magnitude. The estimate was markedly attenuated in magnitude and statistical significance when clinical data were added to the model as risk adjusters (p=.39). IV estimation shifted the estimate in a direction consistent with selective referral, but we were unable to reject the consistency of the linear probability estimates. CONCLUSIONS: Use of only administrative data for volume-outcomes research may generate spurious findings. The IV analysis further suggests that conventional estimates of the volume-outcome relationship may be contaminated by selective referral effects. Taken together, our results suggest that efforts to concentrate hospital-based CHF care in high-volume hospitals may not reduce mortality among elderly patients.

Rehabilitation services after the implementation of the nursing home prospective payment system: differences related to patient and nursing home characteristics.

BACKGROUND: The prospective payment system (PPS) for nursing homes was designed to curtail the rapid expansion of Medicare costs for skilled nursing care. This study examines the changes that occurred in nursing home patients and rehabilitation services following the PPS. SETTING: Free-standing Medicare and/or Medicaid certified nursing homes in Ohio. PRIMARY OUTCOMES: The percent of new admissions receiving therapy and the amount of rehabilitation therapy provided. SAMPLE: A total of 7006 first admissions in 1994-6 (pre-PPS) and 61,569 first admissions in 2000-1 (post-PPS). METHODS: A logistic model predicting likelihood of rehabilitation was developed and validated in pre-PPS admissions and applied to the post-PPS patients. Rehabilitation services were compared in the pre-PPS and post-PPS cohorts overall, stratified by quintile of predicted score, diagnosis group, and by nursing home profit status. RESULTS: Post-PPS patients had less cognitive impairment, more depression, and more family support. The amount of rehabilitation services declined the most in the higher quintiles of predicted likelihood of rehabilitation and among patients with stroke. The percent of patients receiving rehabilitation services increased the most in the lowest quintile and among patients with medical conditions. These changes were greater in for-profit nursing homes. CONCLUSIONS: The implementation of the PPS in nursing homes has been associated with a decrease in the amount of rehabilitation services, targeted at those predicted to receive higher amounts and an increased frequency of providing services targeted at those predicted to be less likely to receive them. The outcomes of the changes deserve further study.

Are we selecting the right patients for stroke rehabilitation in nursing homes?

OBJECTIVE: To examine the effect of stroke rehabilitation in the nursing home on community discharge rates and functional status among patients stratified by propensity to receive rehabilitation. DESIGN: Retrospective cohort. SETTING: Medicaid-certified nursing homes (N=945) in Ohio. PARTICIPANTS: Patients with stroke (N=2013) admitted to an Ohio nursing home. INTERVENTION: Rehabilitation therapy services. MAIN OUTCOME MEASURES: The propensity to receive rehabilitation, used to adjust for selection bias, was calculated for each patient by using a logistic regression model. Community discharge and change in functional status, measured by using a crosswalk to the FIM instrument, were determined 3 months after admission. RESULTS: By 3 months after admission, 36.9% of the patients were discharged to the community, 16.6% had died, and 46.5% remained in the nursing home. The overall effect of rehabilitation on community discharge (relative risk [RR]=1.58; 95% confidence interval [CI], 1.33-1.85) was not homogeneous across subgroups stratified by propensity to receive rehabilitation. Patients less likely to receive rehabilitation, as measured by a lower propensity score, had a significant benefit in terms of community discharge (RR=1.65; 95% CI, 1.35-1.97), but those more likely to receive services did not (RR=1.21; 95% CI, 0.87-1.56). Among long-term nursing home residents, rehabilitation services were not associated with improved functional status. CONCLUSIONS: With respect to community discharge, patients who were less likely to receive rehabilitation therapy appear to receive greater benefit from rehabilitation services than those who were more likely to receive rehabilitation. This finding raises concerns about current selection practices for rehabilitation services. Research is needed to identify the patients most likely to benefit, especially in the present fiscally constrained reimbursement environment.

Evaluation of a commercial electronic medical record (EMR) by primary care physicians 5 years after implementation.

Electronic medical records (EMRs) are gaining increasing prominence in the delivery of healthcare, although the focus is primarily on deploying EMRs. Relatively little research has studied the post-implementation of commercial EMRs. Here we present the results of a web-based survey of all the primary care clinicians in our university affiliated, tertiary care health system. The survey evaluated primary care clinician demographics, usage, and ideas for enhancement of the EpicCare EMR, five year after its initial deployment throughout our healthcare system.